Healthcare Consulting Services
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax
July 9, 2019
Spinal Injection of Tranexamic Acid
In our June 4, 2019 Patient Safety Tip of the Week “Medication Errors in the OR – Part 3” we happened to mention the inadvertent spinal administration of tranexamic acid as one of the medication errors occurring in the OR setting. Tranexamic acid is an antifibrinolytic agent used in the control of traumatic, surgical and obstetric hemorrhage. In 2015, Patel and Loveridge (Patel 2015) did a review of obstetric neuraxial drug administration errors. That review included four deaths from spinal tranexamic acid administered at caesarean section. At that time, they had four key recommendations to avoid such errors:
In a more recent review, Patel et al. (Patel 2019) identified 21 reports in the literature of accidental spinal administration of tranexamic acid injected during spinal anesthesia or analgesia. These included seven elective caesarean sections and six patients having orthopedic surgery.
Death was reported in 10 patients, and 10 of the remaining 11 patients required intensive care admission for management of refractory convulsions and/or tachyarrhythmias.
Typical symptoms and signs include severe pain in the back, buttocks and legs, myoclonus starting in the legs, generalized convulsions, severe tachycardia and hypertension, and ventricular arrhythmia. In addition, there was usually no sensory or motor block as you’d expect if the intended bupivacaine had been administered.
In almost all cases there was an error related to the ampule containing the tranexamic acid. There was similar size and appearance to the ampules of the intended medication (usually bupivacaine or similar agent). Failure to check the label contributed in many cases. One case involved confusion between the IV line and a spinal catheter that had been inserted for chronic pain management.
Some organizational factors that were reported included a lack of formal drug handling or storage policy, and lack of resources. In three cases, syringes or vials containing tranexamic acid were prepared by personnel other than the practitioner administering spinal anesthesia. On one occasion, the tranexamic acid ampule was stored in the same location as local anesthetics. The ampule was passed unchecked from the assistant to the anesthetist, who also failed to check the ampule.
Patel et al. note that all errors could have been prevented if the recommendations in their 2015 paper had been followed. They also suggest that manufacturers of tranexamic acid should be encouraged to design ampules with recognizable size, shape, fonts and color or, alternatively, tranexamic acid might be manufactured in a vial. The also advise that tranexamic acid, and other non‐anesthetic drugs, should be stored in a separate location in or outside the operating room, to limit the possibility of picking up the wrong drug.
Our previous columns on medication errors in the OR have noted one critical factor contributing to many incidents is that one person (the anesthetist) often orders the medication, prepares it, and administers it. That bypasses the usual chain in the medication administration system in which you have several sets of eyes (physician, pharmacist, and one or more nurses) checking the medication. Double checks would be an obvious potential solution. But we don’t see many OR’s in which such double checking actually occurs. Also, barcoding could go a long way to avoid such misadministration. But many OR’s have yet to implement barcoding.
In an editorial accompanying the Patel study, Palanisamy and Kinsella (Palanisamy 2019) focus on two important points: (1) reducing the similarity of the ampules and (2) segregating the storage of the drugs. They noted that tranexamic acid and bupivacaine are both patent‐expired drugs that are supplied by a surprising number of generic manufacturers. They stress that ampules of similar size increase the likelihood of mistakes and suggest manufacturers could make ampules distinctive with different colored neck and head rings in addition to the labelling issues. They also stress that facilities should physically segregate tranexamic acid from commonly administered spinal medications. Because tranexamic acid is not frequently administered, it can be housed in a location that is distinct from anesthetic drugs. Note that we (in our June 4, 2019 Patient Safety Tip of the Week “Medication Errors in the OR – Part 3”) and Patel et al. in the above paper have suggested tranexamic acid might be stored outside the OR. But Palanisamy and Kinsella make a plea not to banish tranexamic acid from the labor and delivery ward and operating room. They note tranexamic acid is a safe, inexpensive and modestly effective treatment and that the number needed to treat for IV tranexamic acid to prevent one maternal death from hemorrhage is 267, whereas the number needed to harm for inadvertent administration of tranexamic acid would be much higher.
It’s hard to contest that last argument. However, hospitals could do an inventory of use of tranexamic acid in each of their OR’s and selectively remove tranexamic acid from those that almost never use it. For example, an OR that is dedicated to ophthalmology cases might never use it. You could still store tranexamic acid in your labor and delivery rooms and those other OR’s where it is frequently used, while still making sure it is not stored in proximity to your anesthetic drugs.
A key lesson is “Don’t store dangerous medications in a location where someone might inadvertently pick it up, prepare it, and administer it”. We learned that lesson many years ago when concentrated potassium chloride was sometimes inadvertently given IV to patients, resulting in fatalities. We also stressed it in our columns (listed below) on the mistaken administration of methylene blue instead of the intended trypan blue in ophthalmology cases.
Some of our prior columns on medication errors in the OR:
March 24, 2009 “Medication Errors in the OR”
May 20, 2014 “Ophthalmology: Blue Dye Mixup”
September 2014 “Another Blue Dye Eye Mixup”
November 3, 2015 “Medication Errors in the OR - Part 2”
June 4, 2019 “Medication Errors in the OR – Part 3”
References:
Patel, S, Loveridge, R. Obstetric neuraxial drug administration errors: a quantitative and qualitative analytical review. Anesthesia and Analgesia 2015; 12: 1570-1577
Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anesthesia 2019; 74(7): 904-914 First Published: April 15, 2019
https://onlinelibrary.wiley.com/doi/abs/10.1111/anae.14662
Palanisamy A, Kinsella SM. Spinal tranexamic acid - a new killer in town. Anaesthesia 2019;74(7): 831-833 Epub April 15, 2019.
https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14632
Print “Spinal Injection of Tranexamic Acid”
July 16, 2019
Avoiding PICC's in CKD
One of the tenets of managing patients with chronic kidney disease (CKD) is planning ahead and being able to avoid “emergency” dialysis. That means we need to anticipate having good vascular access at the time hemodialysis is initiated and thereafter. Preserving veins for future creation of an arterio-venous fistula (AVF) is paramount to ensure better outcomes for patients with CKD who may eventually need hemodialysis.
One of the recommendations from the American Society of Nephrology in the Choosing Wisely campaign is “Don’t place peripherally inserted central catheters (PICC) in stage III-V CKD patients without consulting nephrology.” (Choosing Wisely 2012). The recommendation notes “Venous preservation is critical for stage III–V CKD patients. Arteriovenous fistulas (AVF) are the best hemodialysis access, with fewer complications and lower patient mortality, versus grafts or catheters. Excessive venous puncture damages veins, destroying potential AVF sites. PICC lines and subclavian vein puncture can cause venous thrombosis and central vein stenosis. Early nephrology consultation increases AVF use at hemodialysis initiation and may avoid unnecessary PICC lines or central/peripheral vein puncture.” The evidence base and rationale for this recommendation were published when the recommendation was made in 2012 (Williams 2012).
So, how are we doing with regard to following this recommendation? Paje and colleagues (Paje 2019) looked at hospitalized medical patients who received a PICC in 52 hospitals participating in the Michigan Hospital Medicine Safety Consortium. Unfortunately, they found that placement of PICC’s in those with CKD was common and not concordant with clinical guidelines. Of over 20,000 patients who had PICC’s placed, 23.1% had an estimated GFR (eGFR) less than 45 mL/min/1.73 m2 and 3.4% were receiving hemodialysis. Many were large-diameter lines and multi-lumen PICC’s were placed more frequently than single-lumen PICC’s. PICC placement in these patients was more common in the intensive care unit (ICU) compared to wards (30.9% vs. 19.3%). They also noted that PICC complications occurred in roughly 15% of ward patients and 23% of ICU patients regardless of eGFR status. They did note considerable variation in PICC use rates across hospitals. They were unable to determine how often nephrologist approval for the PICC placement had been obtained.
Obviously, the message is not getting across. So, what should your facility be doing to prevent inappropriate use of PICC’s in these more advanced CKD patients without getting approval from a nephrologist? We wouldn’t count on education to solve this problem. You could, and should, require an order via CPOE for a PICC insertion and then you could use a CDSS alert to remind the practitioner that PICC’s should be avoided in late-stage CKD patients. Of course, you’d also include the other appropriateness criteria for PICC’s that we’ve discussed in our prior columns on PICC use (see list below).
But we suspect at most hospitals a busy physician simply grabs a PICC procedure kit and does not use CPOE. So, this is a problem that calls for use of either a forcing function or constraint. In our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR” we discussed how access to procedure kits should be used to get everyone to do the correct things. Your nursing staff should control the access to the procedure kits. And each procedure kit should have a checklist attached to the outside that must be completed before the kit is opened. On that checklist you would include an item about checking the eGFR and, if the patient has stage III-V CKD, ensure that nephrology has been consulted.
In that column we cited a project at Northwestern University (Barsuk 2011) to re-engineer their processes for compliance with Universal Protocol for bedside procedures. They looked at lumbar punctures, thoracenteses and paracenteses done on the medicine services at their facilities. Analyzing their processes, they found that staff were often unaware of Universal Protocol (or perhaps unaware that it was required not just for OR procedures, but for bedside procedures as well) and that nurses were frequently never notified by physicians when their patients were undergoing such procedures. In their redesigned process the physician initiates the process by entering an order via CPOE with an anticipated time. This order would automatically populate the nurse’s alert list and provide the nurse with a timeout form and notice of a procedure-specific supply kit to procure. Only the nurse has a key to those procedure kits. This is a forcing function that forces the physician-nurse communication to take place. The nurse brings the timeout checklist and the kit to the bedside at the specified time and the nurse and physician go through the timeout procedure, which gets documented in the EMR. Compliance with Universal Protocol went from 16% before to 94% after implementation of this redesigned process.
Take a look at your data. It should be easy for you to identify patients in whom a PICC had been inserted. Then you should be able to easily stratify by eGFR, which is available today in almost all patient records. If you confirm high rates of PICC use in patients with Stage III-V CKD, as we suspect you will, make sure you implement procedures like those above to begin avoiding inappropriate PICC use.
Some of our other columns on IV access, central venous catheters and PICC lines:
January 21, 2014 “The PICC Myth”
December 2014 “Surprise Central Lines”
July 2015 “Reducing Central Venous Catheter Use”
October 2015 “Michigan Appropriateness Guide for Intravenous Catheters”
March 27, 2018 “PICC Use Persists”
February 26, 2019 “Vascular Access Device Dislodgements”
References:
Choosing Wisely. Recommendation from the American Society of Nephrology: Don’t place peripherally inserted central catheters (PICC) in stage III-V CKD patients without consulting nephrology. Released April 4, 2012
Williams AW, Dwyer AC, Eddy AA, et al. Critical and Honest Conversations: The Evidence Behind the “Choosing Wisely” Campaign Recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol 2012; 7: 1664-1672
https://cjasn.asnjournals.org/content/clinjasn/7/10/1664.full.pdf
Paje D, Rogers MA, Conlon A, Flanders SA, Bernstein SJ, Chopra V. Use of Peripherally Inserted Central Catheters in Patients with Advanced Chronic Kidney Disease: A Prospective Cohort Study. Ann Intern Med 2019; Epub ahead of print 4 June 2019
Barsuk JH, Brake H, Caprio T, et al. Process Changes to Increase Compliance with the Universal Protocol for Bedside Procedures. Arch Intern Med. 2011; 171(10): 947-949
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/487053?resultClick=1
Print “Avoiding PICC’s in CKD”
July 23, 2019
Order Sets Can Nudge the Right Way or Wrong Way
Standardized order sets are powerful tools that can improve clinician efficiency and improve patient safety. They can “nudge” you in a good way. For example, they can be used to remind you to consider DVT prophylaxis and provide you with the best options for that prophylaxis. Or they can ensure you use correct drug names and dosages that are appropriate. But they can also nudge you in the wrong direction. When hospitals first began to use order sets (paper- or computer-based) there was a tendency to try to cover all contingencies. For example, order sets might include prn orders for sleep meds, laxatives, antacids, etc. Often, these were included so a clinician did not have to be wakened at night to order such medications. Long ago, we recognized that putting too many options in an order set, particularly those using a “checkbox” format, often resulted in inappropriate orders for many patients. In our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” we noted ISMP’s guideline on order sets cautioned against including blanket-type orders (eg. laxatives, sleep meds, antiemetics, antidiarrheals, antacids, etc).
Remember, any options you include in an order set have a good chance of being selected and ordered. For example, if you include Dilaudid/HYDROmorphone as an option for postop analgesia, there is a good chance someone will order it. In our many columns on the dangers of that drug (see list below), we note that many clinicians fail to recognize the equipotency issues of several opioids and that clinicians often underestimate the relative potency of Dilaudid/HYDROmorphone. Hence, we prefer not to include Dilaudid/HYDROmorphone as an option on a standardized order set but, recognizing that there are a few select circumstances where it may be appropriate, you can create a link in your order set to “other analgesics”.
Keep in mind that “default bias” is a very powerful cognitive bias. In our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts” we noted the importance of considering appropriate default options when designing order sets. One of the cognitive biases we see is the “default bias”, in which it is a natural tendency to select default options when several options are possible. In our April 30, 2019 Patient Safety Tip of the Week “Reducing Unnecessary Urine Cultures” we noted how clinicians and researchers at Barnes-Jewish Hospital implemented a program to reduce unnecessary cultures (Munigala 2019). Their intervention consisted of notifications to providers, changes to order sets, and inclusion of urine culture reflex tests in commonly used order sets. The CPOE intervention they implemented was setting the default option to urine dipstick testing followed by a bacterial culture if positive (i.e. reflex testing), rather than a culture alone, This resulted in a 45% reduction in the urine cultures ordered. That intervention saved approximately $104,000 in laboratory costs alone over the 15-month period plus likely savings from reduced antibiotic use and less contribution to the emergence of resistant organisms.
Another recent study (Strauss 2019) used a multifaceted strategy to reduce unnecessary ordering of certain laboratory tests that add little value to patient management at significant cost. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), were the examples they targeted. They created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback, and removed AST and BUN from institutional order sets. This resulted in ratios of AST/ALT and BUN/Cr decreasing significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), and a projected annualized cost savings of $221,749.
Li and colleagues (Li 2019) recently evaluated how well standardized order sets were serving their clinicians. Using data from the EHR on all orders of medication, laboratory, imaging and blood product items, they focused on four indicators: infrequent ordering of order set items, rapid retraction of medication orders from order sets, additional a la carte ordering of items not included in order sets and a la carte ordering of items despite being listed in the order set.
Ordering rates for individual order set items varied greatly, ranging from 0.001% to 100%, with a median of 4.1%. Laboratory items had higher median ordering rates (11.5%) in general than medications (2.3%,), imaging (4.7%) and blood product items (2.6%).
Regarding medication orders retracted within 30 minutes, 2.2% ordered via order sets were retracted, compared to 3.9% that had been ordered ala carte. But there was considerable variability. 3% of medications ordered from order sets were significantly more likely to be retracted than if the same medication was ordered ala carte. Order set medication items with ordering rates in the lowest quartile were approximately twice as likely to be retracted than those in the other quartiles.
They then looked at items that were additionally ordered ala carte within 10 min. of an order set use more often than the median ordering rate of items in the corresponding order set. 39% of order sets had such an item commonly added ala carte, with a median of 4 distinct additional a la carte items per order set.
Lastly, they looked at items that were ordered ala carte even though they had been in the order set used. 45% contained at least one such ‘a la carte over order set’ item, with a median of 4 distinct items per order set.
Overall, their analysis found that many order sets were seldom used and many order sets
may be “bloated” with low yield items. Rarely used items were also more likely to be rapidly retracted. Furthermore, many order sets may also be missing items that users need.
The Li study emphasizes the critical importance that any time you roll out a new order set (or a new alert or other clinical decision support tool, for that matter) you must monitor usage of that order set. You need to review how often it is used and whether the desired goals are achieved, and whether unintended consequences occur. You need to solicit feedback from users. You need to have a formal process by which you assess all the above. Sometimes our most well-intended evidence-based patient safety interventions end up causing unintended consequences that may produce patient harm. And, don’t forget you need to review all your order sets periodically. Clinical evidence and guidelines often change over time and you don’t want to have items in your order sets that are outdated and no longer recommended practices.
Our discussion on order sets should also include some comments on “Do not use” abbreviations. You, of course, should be using ISMP’s List of Error-Prone Abbreviations (ISMP 2017), rather than The Joint Commission’s more succinct list of “Do not use” abbreviations. In our several columns on dangerous abbreviations (see, for example, our December 22, 2015 Patient Safety Tip of the Week “The Alberta Abbreviation Safety Toolkit”), we note that, as you update your “Do not use”, you need to review all your order sets. When we did this at one hospital, we found numerous dangerous abbreviations still sitting in some old order sets, some “customized” order sets used by individual clinicians, and even in some third-party vendor order sets.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
See our series of columns on the dangers of Dilaudid/HYDROmorphone listed below:
References:
Munigala S, Rojek R, Wood H, et al. Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infection Control and Hospital Epidemiology 2019; Published online: 21 February 2019: 1-6
Strauss R, Cressman A, Cheung M, et al. Major reductions in unnecessary aspartate aminotransferase and blood urea nitrogen tests with a quality improvement initiative
BMJ Quality & Safety Published Online First: 09 May 2019
https://qualitysafety.bmj.com/content/early/2019/05/08/bmjqs-2018-008991
Li RC, Wang JK, Sharp C, et al. When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record. BMJ Quality & Safety 2019; Published Online First: 04 June 2019
https://qualitysafety.bmj.com/content/early/2019/06/04/bmjqs-2018-008968
ISMP (Institute for Safe Medication Practices). List of Error-Prone Abbreviations. ISMP 2017; October 2, 2017
https://www.ismp.org/recommendations/error-prone-abbreviations-list
Print “Order Sets Can Nudge the Right Way or the Wrong Way”
July 30, 2019
Lessons from Hospital Suicide Attempts
Suicide in the hospital is a “never event”. Yet this remains a problem, both for behavioral health hospitals and general hospitals. A couple incidents from the most recent release of California Department of Public Health hospital incidents reinforce some lessons we have focused on in the past.
Many of our columns on hospital suicides have highlighted the problem of patients attempting suicide while in bathrooms in areas other than behavioral health units. The radiology suite is one area we have always talked about because behavioral health patients may need to go there for imaging studies and bathrooms there may not be ligature-proof and may be capable of being locked from the inside. The first CDPH case (CDPH 2019a) illustrates the same vulnerability – but this time in the emergency department. The patient was admitted to the ED from the facility’s chemical dependency unit because of attempted suicide and was placed on 72-hour involuntary hold. He was assigned a 1:1 sitter but the sitter allowed the patient to go to the ED restroom alone, where he closed and locked the door. A registered nurse later found the patient kneeling on the restroom floor with the call light cord around his neck. The patient was assisted back to his room and was subsequently admitted to the General Acute Care Hospital psychiatric unit.
The sitter was a “float” who usually worked on a transitional care unit rather than the ED. She was also not used to working with suicidal patients. The sitter did not have a key to the bathroom and did not know where the key was kept. A nurse and the sitter responded to the nurse call light (presumably triggered when the patient attempted to hang himself by the call light cord).
The house nursing supervisor noted that, when the ED requests a sitter, she pulls one from one of the floors in the hospital. The sitter receives an orientation once they arrive in the unit. They receive basic training and are given “additional instructions”, but it was not clear what training they were given for dealing with psychiatric or suicidal patients.
The facility’s plan of correction involved multiple educational interventions aimed at ensuring sitters understood their roles and responsibilities. The facility also replaced the nurse call light cord in the ED bathroom with a psychiatric safe breakaway cord to reduce the chance it could be used as a ligature.
Lessons from this case:
Are you required by The Joint Commission to have ligature-resistant standards in the emergency department? The answer is probably no. Their standards FAQ’s state “Emergency departments do not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment” (TJC 2018a). However, if you provide a “safe room” in your ED for patients at high risk for suicide TJC states: “The organization should remove all items that can be removed from the room and provide an appropriate level of monitoring based upon patient’s suicide risk and the ligature/self-harm items that remain in the environment to ensure patient care is provided in a safe environment. The organization is expected to develop and implement a policy/procedure to direct staff, provide education to staff as to the procedure, and ensure demonstrated competence and compliance. If the organization has a designated “safe room,” The Joint Commission expects this room to be ligature resistant.” (TJC 2018b).
Regarding the role of the sitter, The Joint Commission requires the staff member to immediately intervene should the patient attempt self-harm. Their standards FAQ’s (TJC 2019) states “…monitoring of patients at high risk for suicide, the monitoring should be constant 1:1 (at all times, including while the patient sleeps, toilets, bathes, etc.) and the monitoring must be linked to the provision of immediate intervention by a qualified staff member when required.”
The second CDPH case (CDPH 2019b) involved a patient who jumped or fell 30 feet to a concrete patio after escaping from a behavioral health unit. The patient was admitted to a Mental Health Unit on a 14-day hold order after he had attempted to hang himself at home. However, he managed to get out of the locked MHU, go outside and jump down to a concrete patio, which caused multiple traumatic injuries. The CDPH investigation and video tapes revealed that the patient had been behind an administrative staff person who left the MHU via a door that is usually locked. The patient followed the staff person and reached the door as it closed but before it fully closed and locked. He was observed peering through the door window and then entering the outer corridor. The video then showed him walking to a lobby and entering an elevator. When another patient alerted staff that the patient was missing, an immediate search was undertaken. The MHU RN Supervisor found the patient lying on the patio covered in blood, trying to move, moaning and stating, "Just let me die." It was later determined he had jumped or fallen about 30 feet to that concrete patio.
The administrative staff person had never been oriented to the MHU and never received specific training on making sure the MHU locked doors were secured when going in and out and there was no formal policy for such orientation to the MHU.
Lessons from this case:
In our October 6, 2015 Patient Safety Tip of the Week “Suicide and Other Violent Inpatient Deaths” we noted that another potential vulnerability has to do with fire alarms. In one case a patient pulled a fire alarm which automatically unlocked doors on a behavioral health unit, allowing him to escape and jump to his death from a rooftop (Pfeiffer 2010). After we heard about that case, we began to include inspection of stairwells and rooftop access points adjacent to behavioral health units in our patient safety walk rounds or environmental walk rounds.
In our September 18, 2018 Patient Safety Tip of the Week “More on Hospital Suicides” we noted another case which did not involve an actual suicide but serves as a reminder of how patients may use fire alarms to facilitate elopement (Fettes 2018). A patient on a behavioral health unit set his mattress and bedding on fire, triggering the facility's fire alarm. The alarm automatically disarmed the facility's fire doors and the patient left the unit. Fortunately, he was later found and returned to the unit. But the case illustrates a problem we’ve seen before. The behavioral health unit involved did not have a specific policy for "a combined fire and security incident". You’ll recall we have recommended that facilities consider combining safety drills to account for such incidents. For example, you could do a fire drill and then immediately do a drill for a missing patient (or an abducted child).
Some of our prior columns on preventing hospital suicides:
Some of our past columns on issues related to behavioral health:
References:
CDPH (California Department of Public Health). Complaint Intake No: CA00495270 Published June 18, 2019
CDPH (California Department of Public Health). Complaint Intake No: CA00317773 Published June 18, 2019
Pfeiffer R. Man survives plunge from roof of hospital. Niagara Gazette 2010; October 17, 2010
Fettes J, Scott E. Patient escapes from Canberra Hospital's mental health unit by starting fire, disarming fire door. ABC (Australia) News 2018; Posted 29 Aug 2018
http://www.abc.net.au/news/2018-08-30/mental-health-patient-escapes-canberra-hospital/10179584
TJC (The Joint Commission). Standards FAQ Detail. Ligatures and Suicide Risk Reduction - Emergency Department - Ligature-resistant Requirements. The Joint Commission 2018; June 27, 2018
TJC (The Joint Commission). Standards FAQ Detail Ligatures and Suicide Risk Reduction - Emergency Department - Ligatures Risks That Cannot Be Removed. The Joint Commission 2018; June 27, 2018
TJC (The Joint Commission). Standards FAQ Detail. Ligature and Suicide Risk Reduction – Video Monitoring of Patients at High Risk for Suicide. The Joint Commission 2019; March 07, 2019
Print “Lessons from Hospital Suicide Attempts”
August 6, 2019
Repeat Adverse Drug Events
Some adverse drug events may be unpreventable. But how about those that are repeat adverse drug events? Most of those are preventable. How often do those occur? A new Canadian study quantifies that issue and offers insight into contributing factors.
Hohl and colleagues (Hohl 2019) analyzed data from patients who visited the emergency department for adverse drug events in 3 hospitals in British Columbia. They found that 32.5% were repeat events (1.8% had two repeat events), and 75.3% of these were deemed probably or definitely preventable, as re-exposure to the culprit medication or repeat withdrawal of an indicated medication was inconsistent with best medical practice.
Patients having renal failure or a mental health diagnosis were more likely to have repeat adverse drug events. Most repeat adverse drug events were moderate in severity (66.5%) and resulted in temporary harm (81.5%). Significantly, among patients with repeat events, 38.4% were admitted to the hospital.
Among repeat events, 64.6% were due to re-exposures to previously harmful medications, while the remainder were attributed to other causes, including repeat medication withdrawals or dosing problems (e.g., repeat nonadherence with antiepileptics causing repeat seizures). 75.5% of repeat events were attributable to a single drug. Coumarin derivatives (12.4%), opiates (12.1%) and insulins (8.1%) were most commonly implicated.
Hohl et al. note that repeat adverse drug events associated with outpatient medications in their study “were 100 times more common than events resulting from medication transcribing, dispensing and administration errors and 7 times more common than drug interactions, which are the focus of interaction-checking software”. They hypothesize that the high rate of repeat events in their study is due to a lack of standardized documentation of adverse drug events in medical records and to suboptimal communication between care providers who diagnose and treat serious adverse drug events to outpatient medications (typically hospital-based providers) and physicians who prescribe outpatient medications for chronic disease management (typically community-based providers).
The authors state that patients who have a documented adverse event associated with a medication should probably only be re-exposed to a culprit medication if there is a clear indication for re-exposure and a strong contraindication is absent. Aye, there the rub! Where is the documentation of a prior adverse event?
In our August 2019 What's New in the Patient Safety World column “Including Indications for Medications: We Are Failing” we again mentioned a theme we’ve stressed in multiple columns (listed below): we need to be documenting reasons for discontinuations of medications. It may be important to know whether a medication was discontinued because of:
For example, I might consider prescribing a beta blocker for migraine prophylaxis and the patient tells me that he/she was once on that medication. It would be important for me to know whether it had been discontinued because it was ineffective for the initial indication (other than migraine prophylaxis) or because of an untoward side effect or true allergy.
Not only do we lack systems for documenting reasons for discontinuation, we also do a poor job in communicating when a drug has been discontinued. The columns listed below have all dealt with the issue of documenting drug discontinuation, not only to other potential prescribers for a patient, but also to pharmacies that might continue to dispense drugs that had been discontinued.
In our August 28, 2018 Patient Safety Tip of the Week “Thought You Discontinued That Medication? Think Again”, and other columns. we highlighted a critical issue: stopping a medication is much different than starting one. Starting a medication requires an active process – you either write a prescription, enter one into a computer, or call the pharmacy. You are usually in a situation where you can utilize an electronic order system (CPOE or e-prescribing tool) and you may have access to the many clinical decision support tools in those systems. But discontinuing a medication is often more passive – you might get a call from your patient after hours and just tell the patient over the phone to stop it when the patient tells about a potential side effect. You don’t call the pharmacy to stop it. And, if there was no associated office visit, you might even forget to update the patient’s medication list in your EMR (or paper records) until the patient’s next office visit.
With today’s integration of the EMR to the physician’s smartphone, almost all opportunities to do e-discontinuation should be done with a formal process that should include more than just the discontinuation order. The EMR system could ask “Have you notified the patient to discontinue the medication?”, “What is the reason for the discontinuation?”, and “Do you wish to notify the patient’s pharmacy of the discontinuation?”. The system’s clinical decision support tools should then also consider whether any drug-drug interactions might be in play that would necessitate changing the dosage of another medication.
And don’t forget there is one other mechanism by which discontinued medications get inappropriately continued. Our February 28, 2017 Patient Safety Tip of the Week “The Copy and Paste ETTO” reminds us how the copy/paste function in today’s healthcare IT systems can lead to erroneous medication lists that might result in a patient being inappropriately restarted on a medication that had actually been discontinued.
Once systems are in place to capture drug discontinuations and reasons for discontinuation, clinical decision support systems need to be capable of flagging these when someone attempts to prescribe a medication the patient had previously been taking. In some cases, such as a dose-related side effect, it may still be appropriate to re-prescribe a medication. But in others, where an allergy or adverse reaction occurred, a flag should warn the prescriber of that prior problem.
We’d be remiss if we did not mention two other recent excellent resources that deal with a related issue – documenting and communicating drug allergies. ISMP (ISMP 2019) just published an alert “New Recommendations to Improve Drug Allergy Capture and Clinical Decision Support” that draws heavily on ECRI Institute’s Partnership for Health IT Patient Safety (Partnership 2019) publication “Safe practices for drug allergies—using CDS and health IT”. They review the many issues related to both capturing allergy information and designing clinical decision support tools that provide actionable alerts without overloading the system with useless ones. They then make the following 4 recommendations:
We encourage you to read both the ISMP and Partnership documents. They stress the importance of patient engagement in correctly documenting and categorizing drug allergies and maintaining an up-to-date list. The same can be applied to documenting discontinuation of any medication and reasons for such discontinuation.
Some of our other columns on failed discontinuation of medications:
May 27, 2014 “A Gap in ePrescribing: Stopping Medications”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
February 2018 “10 Years on the Wrong Medication”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
References:
Hohl CM, Woo SA, Cragg A, et al. Repeat adverse drug events associated with outpatient medications: a descriptive analysis of 3 observational studies in British Columbia, Canada. CMAJ Open 2019; 7(3): E446-E453 July 18, 2019
http://cmajopen.ca/content/7/3/E446.full
ISMP (Institute for Safe Medication Practices). New Recommendations to Improve Drug Allergy Capture and Clinical Decision Support. ISMP Medication Safety Alert! Acute Care Edition 2019; 24(14): July 18, 2019
Partnership for Health IT Patient Safety. Safe practices for drug allergies—using CDS and health IT. ECRI Institute. 2019; 1-42
https://assets.ecri.org/PDF/HIT-Partnership/ECRI-Drug-Allergy-Toolkit.pdf
Print “Repeat Adverse Drug Events”
August 13, 2019
Betsy Lehman Center Report on Medical Error
We, and others, have often tried to quantitate the human and financial costs attributable to medical error. Cost estimates often range widely for the same type of medical error, largely because the methodologies used have differed considerably and because it has often been difficult to separate out which costs were the result of the error and which would have occurred anyway.
The Betsy Lehman Center for Patient Safety in Massachusetts recently reported their analysis of the financial costs of medical errors and the behavioral, physical, emotional, and financial harms to those who suffered the errors (Betsy Lehman Center 2019).
The analysis used claims data from Medicare and the Massachusetts All-Payer Claims Database (APCD). The latter includes both commercial health insurance and Medicaid claims. They focused on 98 diagnostic codes known to be associated with preventable harm events. They then calculated the probability that these claims were related to preventable error and estimated the additional health care costs resulting from those events by comparison to patients matched for similar conditions who did not have claims for these codes.
In addition, they identified 998 people (from 5,001 randomly selected households in a previous Massachusetts health survey) who reported a medical error in the previous five years in their own care or in the care of a family or household member. They then conducted a 30-question “re-contact survey” with 253 of those respondents about the physical, emotional, behavioral, and financial impacts of the errors, as well as the communication and support offered by providers after the errors. Ten of the re-contact survey questions allowed for open-ended narratives. For a comparison group, 371 respondents who had reported no recent experience with medical error to ask a brief set of questions regarding their perceptions of the health care system and patient safety.
Overall, they identified almost 62,000 preventable harm events that resulted in over $617 million in excess health care insurance claims. That accounts for about 1% of the total Massachusetts expenditures on healthcare in 2017. That is likely an underestimate because the most common types of errors (eg. medication and diagnostic error) could not be identified through health insurance claims data.
Pressure ulcers, postoperative and other hospital-acquired infections, and hemorrhage were the most frequently reported events. The medical errors occurred in all healthcare settings: hospitals 41%, emergency departments 15%, doctor’s offices or clinics 27%, and other 17%.
We’ve always had a problem with studies that rely on administrative data. There is considerable variability in the coding practices of hospitals. We’ve seen “good” hospitals code for lots of complications and “bad” hospitals code for few. We’ve actually found average length of stay (sLOS) for specific conditions to be a much better indicator of whether complications or adverse events occurred. Nevertheless, the methodology used in the Betsy Lehman Center report at least provides an estimate of the financial impact of medical errors.
But, forget the statistics! The real lessons in this report come from the behavioral, physical, emotional, and financial harms to those who suffered the errors and the behavior of the hospitals and healthcare providers. Perhaps the most important finding in the report deals with what the facilities and healthcare providers did when errors occurred. Massachusetts does have a law requiring providers to disclose medical errors that cause significant harm and encourages apology, But, only 19% of the patients said that they received an apology after the medical error. Only one quarter (25%) of respondents were offered one or more types of emotional, functional, or financial support services. The most common additional help offered among all respondents reporting experience with a medical error was spiritual support (13%).
The report concludes that over 60% of people were dissatisfied with the communication from providers after an error. But open communication was linked to lower levels of adverse emotional impacts and health care avoidance.
Among the 28 percent of respondents who reported receiving an acknowledgment of the error, 23 percent reported also receiving an explanation of the actions being taken to prevent similar errors from happening in the future.
Nearly 40 percent of respondents didn’t discuss the error with anyone other than family and friends, primarily because they believed it “would not do any good.” Of those who did, almost two-thirds (62%) said they hoped to prevent harm to future patients by speaking up. Lawyers were consulted just seven percent of the time and errors were reported to government agencies only one percent of the time.
A key finding was that medical errors are associated with long-lasting loss of trust and avoidance of health care. 57% of those who experienced an error said they sometimes or always continue to avoid the individual doctors or the health care facility involved in the error. In fact, more than a third of all respondents said that they continue to sometimes or always avoid all medical care.
There were also frequent financial impacts on those who experienced a medical error. Nearly half (49%) reported two or more financial impacts from the errors. That often involved more health care expenses and loss of work.
Particularly rich were some of the specific comments made by patients who suffered errors. Many “expressed empathy for the clinicians and staff involved in the errors, noting that they seemed stressed, harried, burnt out or otherwise unable to do their jobs well under current constraints.” They often had significant insight into factors contributing to the errors, such as breakdowns in systems, teamwork, and communications, to workforce factors.
Transparency and open communication are critical after a medical error. Disclosure and apology are key elements to helping patients and families deal with what has happened to them. They also help providers deal with what’s happened. We hope you will remember all our previous columns on disclosure and apology listed below. Also, “communication and resolution” programs (see our April 2018 What's New in the Patient Safety World column “More Support for Communication and Resolution Programs”) may be particularly important for those who have suffered financial hardships resulting from errors.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “What’s Happening to “I’m Sorry”?”
October 2017 “More Support for Disclosure and Apology”
April 2018 “More Support for Communication and Resolution Programs”
Other very valuable resources on disclosure and apology:
References:
Betsy Lehman Center for Patient Safety. The Financial and Human Cost of Medical Error... and how Massachusetts can lead the way on patient safety. Betsy Lehman Center 2019; June 2019
https://www.betsylehmancenterma.gov/research/costofme
Full report
https://www.betsylehmancenterma.gov/assets/uploads/Cost-of-Medical-Error-Report-2019.pdf
Executive summary
https://www.betsylehmancenterma.gov/assets/uploads/CoME-Exec-Summary.pdf
Key Findings Graphic
https://www.betsylehmancenterma.gov/assets/uploads/Cost-of-Medical-Error-Key-Findings.pdf
Print “Betsy Lehman Center Report on Medical Error”
August 20, 2019
Yet Another (Not So) Unusual RSI
Hard to believe it’s been over 3 years since our last column on RSI’s (retained surgical items) or RFO’s (retained foreign objects), especially since “unintended retention of a foreign body” remains The Joint Commission’s top reported sentinel event. There were 111 such events reported to The Joint Commission in 2018 (TJC 2019a) and 116 in 2017 and 60 so far in the first half of 2019 (TJC 2019b).
But there have been some interesting, and troubling, trends. While surgical sponges remain the most frequently retained surgical items, the nature of retained items has been changing over the last few years and a number of unusual items have been reported.
Three cases recently published by the California Department of Public Health (CDPH) provide insight into factors contributing to retention of some surgical items.
The first incident recently published by the CDPH (CDPH 2019a) illustrates how multiple factors contributed to retention of a viscera retainer after a hernia repair. That retained foreign object was found during a second surgery conducted after the patient presented several weeks later with an infected wound that had opened.
The original case had been the last case of the day and the most complicated. It started out as a laparoscopic hernia repair but was converted to an open procedure because the hernia was large. During the procedure, the surgeon requested a silastic viscera retainer (VR). The relief circulating RN (CRN) was unfamiliar with this and the OR tech told him what it as and where to find it in a storage cabinet. The CRN “was nervous” and dropped the VR as he attempted to put it on the sterile field and it fell to the floor. He got another VR and put it on the sterile field. The VR that fell on the floor was later put in the kick bucket. Apparently neither VR was written on the whiteboard.
During the surgery the viscera retainer was placed over the intestines to prevent suturing the mesh to the bowel, then the mesh was placed on top.
At some point during the surgery there was a change in personnel. The First-Assist Physician’s Assistant (FAPA) stated she stayed 2 hours past her shift to assist the surgeon and then she asked to leave the surgery. An OR tech came in to relieve the FAPA. The OR tech stated he did not remember receiving report from the FAPA that a VR was used during the surgery. The OR tech also stated he did not remember seeing the ring or the tail from the VR on the surgical drape outside the patient’s incision.
The surgeon, when interviewed several months after the initial surgery, could not recall putting the VR in or taking it out, but did recall, as he was closing, asking for a count and being told it was correct, so he proceeded to close. Both the CRN and the OR tech saw the VR in the kick bucket and thought the count was correct.
It was not clear who actually put the VR in, but it was speculated that might have been the FAPA before being relieved by the OR tech.
The second case (CDPH 2019b) involved retention of a surgical ribbon malleable instrument, measuring 12.99 inches by 2 inches after a C-section and tubal ligation surgery. The patient returned to the ED with abdominal pain 29 days after surgery and CT scan showed a large metallic density foreign body.
Specialty technician (Tech 1) explained that, during the third count, she was holding a retractor while assisting the surgeon to retract the patient’s skin. Tech 1 stated that she started counting retractors from the patient to the table by visualizing the retractor and verbally counting out the number corresponding to that retractor. Tech 1 advised she counted 7 retractors. However, she explained that she verbally out load said the number “8”, assuming the eighth retractor was already inside the basket. Tech 1 stated “I did not have a visual of the eighth retractor. I assumed the eighth retractor was inside or behind the basket.” (The basket is a metal wire container where the instruments are placed).
The Surgical Services Director explained that the surgical team staff had not performed the instrument counts as mandated by facility policy, explaining that the surgical instruments were not counted audibly nor viewed concurrently by the circulating nurse and the scrub tech and confirming that the eighth retractor was not visualized by the two surgical staff.
Tech 1 explained that the “third” count occurred at the surgical suturing of the peritoneum. She stated that several distractions occurred during this part of the procedure. The primary surgeon dismissed the assistant surgeon at this point of the procedure. Tech 1 indicated that she then assumed the role of assistant to the primary surgeon. Tech 1 described having to hold an instrument to retract the wound with her right hand, while holding a needle holder with her left hand in preparation for the surgeon's next step in the procedure. Her attention to the surgeon’s needs made it difficult for her to visualize all the retractors as the counts were performed. When the circulating nurse named a countable item, the tech used her head to point to the countable item. At this point, the patient began to cough, and the tech thought she might have vomited. At this point the surgeon asked for an instrument to hold back the wound as the patient’s body movement interrupted the surgical suturing of the wound. Tech 1 handed the surgeon a ribbon malleable retractor.
Tech 1 also explained that the ribbon malleable retractor was usually placed inside or in back of the basket. The circulating nurse stated that during the third count she called out “retractors” and thought the tech verbally replied aloud the number “8”. She said she did not actually see that retractor herself. Neither the nurse nor the tech actually saw the 8th retractor. They assumed it was in the basket.
There were several other distractions as the primary surgeon informed the assistant surgeon to leave. The surgeon’s phone rang several times during the third count, before being answered by the anesthesiologist. The patient had also vomited, which is why the surgeon asked for the malleable ribbon retractor.
The third case (CDPH 2019c) also involved retention of a ribbon retractor, measuring about 33 cm long, 5 cm wide, and one millimeter in thickness, after an abdominal hysterectomy by a resident physician. The day after surgery the patient complained of left sided chest pain radiating to her shoulder and a CXR was read as showing a left lower lobe infiltrate with small amount of pleural fluid. The patient was discharged but 20 days post-op she returned with abdominal pain and X-rays show the foreign body (this was actually the “lower lobe infiltrate” previously seen on CXR).
According to the surgical tech (ST), the surgeons used a standard laparotomy tray but, when they closed the abdomen, they asked for a malleable ribbon retractor. Apparently, only 2 counts were done. No final count was performed. “We didn't do final count for instruments, because (the} first (count} was correct.”
So, there is clearly a pattern in these cases.
First, and foremost, counts need to be conducted under “sterile cockpit” conditions. That means that all must focus attention on the count and there should be no extraneous conversations or other distractions.
Communication breakdowns are a key feature of most sentinel events and these are no different. In the first case, the OR tech stated he did not remember receiving report from the FAPA that a VR was used during the surgery.
Third, the potential impact of personnel changes is obvious in the above examples. In one case, the role of one of the persons responsible for the count was changed and she now was performing two roles, causing less than ideal attention to doing the count.
Other distractions included the surgeon’s phone ringing several times during a count. The issue of personal phones in the OR is beyond the scope of today’s column but the case at hand is a great example of a reason we counsel against allowing phones in the OR. Our Patient Safety Tips of the Week May 21, 2013 “Perioperative Distractions”, March 17, 2015 “Distractions in the OR”, and July 21, 2015 “Avoiding Distractions in the OR” had detailed discussion about use of cell phones and other wireless devices in and around the OR with multiple examples of distractions related to such in the OR. There are a multitude of issues related to cell phones in the OR including not only interruptions and distractions but also infection control issues, security and confidentiality issues, and detrimental effects on communication in the OR. Our recommendation is for all the OR team to leave their cellphones at the main OR desk where someone can triage incoming phone calls and messages.
Time of day was clearly a factor in the first case. It was the last case of the day and the First-Assist Physician’s Assistant (FAPA) stated she stayed 2 hours past her shift to assist the surgeon and then she asked to leave the surgery. In the other, it was not clear why the assistant surgeon was “dismissed” (was it also related to time of day?). Time of day is relevant for the fatigue factor, time pressures, and for contributing to the personnel changes.
Other unanticipated events were also contributing factors. In one, the original item fell on the floor, so a second item had to be put into the sterile field. In another, the patient began to vomit and move around.
There was also a common cognitive bias in at least one of the cases. That is the bias where we “see” what we expect to see and the related cognitive bias “inattentional blindness”. The tech assumed the retractor was in or behind the basked where the instruments were placed even though she did not actually see the instrument.
Unfamiliarity with the device played a role in at least one of the above cases. In the first case, the circulating nurse did not know what the device was or where it was located. The “ring” attached to the device was likely also inadequately anchored to remain visible.
Lastly, each of these cases involved problems with the “final” count. There is typically a count done when the wound cavity is closed and then a final count after the skin wound is closed. Most surgical instruments are introduced well before the wound cavity closure stage. But, in the cases with these retractors/retainers, the instrument is often introduced only after the penultimate count (the one following wound cavity closure) has been done. There is probably a natural tendency to forget to add that item to the whiteboard or whatever other tool is being used to log in instruments. This is also relevant with regard to the “methodical wound exploration” (MWE). The MWE is typically done before the “closing” count. But that means there is no MWE after the wound cavity is closed and the skin is sutured, i.e there is no MWE done just before the “final” count.
Also striking in the CDPH cases were the missed opportunities to identify the RSI soon after the fact, causing the patients unpleasant symptoms for several weeks before the correct diagnosis was made.
When we first planned this column many months ago, it was titled “Yet Another Unusual RSI”. But it turns out it is not so unusual. In fact, the most frequently reported retained instrument is the malleable or ribbon retractor according to NoThing Left Behind® (NoThing Left Behind® 2019). NoThing Left Behind® states “we have a better understanding of why malleable retractor cases have occurred. Usually during the closure of the wound the malleable retractor has been added to the field often as an add-in to the case, rather than as a part of the instrument tray. In most of the cases there has been some kind of distraction which has diverted attention from the field and the malleable has slipped away out of view. This alone should not lead to retention because the practice of instrument counting should detect the missing item. However either the instrument counts weren't performed or the added-on malleable wasn't included in the counting documentation and the retractor has been left inside.”
Interestingly, the solution proposed to prevent retention of the malleable ribbon retractors is use of the plastic fish viseeral retainer, which was the item retained in the first CDPH case. “These cases can be prevented with the use of a plastic fish visceral retainer which has a long cord and a ring at the end. The ring is clamped to the surgical drapes when the retainer is placed inside the abdomen during closure. The cord and ring are actually the safety part of the retainer.” (NoThing Left Behind® 2019).
Back in our November 5, 2013 Patient Safety Tip of the Week “Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects” we mentioned another case of a retained Glassman viscera retainer. That was from the investigation of a RFO reported by the California Department of Public Health (CDPH CA00235788). In this case the retained foreign object was a Glassman viscera retainer, which is a fish-shaped soft flexible device that folds into a roll and is used to shield from nicks and punctures. All the “counts” in the case were reported to be correct. But apparently when the “fish” was added to the surgical field it was not added to the count verbally or on the count board (see our January 8, 2013 Patient Safety Tip of the Week “More Lessons Learned on Retained Surgical Items” regarding addition of items to the surgical field). In addition, the “fish” apparently has a string attached to promote retrieval but that string had been cut by the surgeon. Guidelines for surgical sponges have always emphasized the importance of not cutting or altering the sponges. Obviously the same should apply to other things, like the “fish”.
In the current CDPH case (CDPH 2019a) staff did not recall seeing the fish ring or the connecting “tail”. The hospital’s plan of correction included re-educating surgical staff on use of a viscera retractor and methods for anchoring the FISH ring when the view is obscured. So it’s clear that you need to use the “Fish” correctly to take advantage of its built-in safety features.
While sponge accounting systems are at the top of everyone’s list of tools to prevent RSI’s because surgical sponges are far and away the most commonly retained surgical items, our previous columns warn you not to lose sight of the fact that all sorts of other RSI’s have been appearing more and more (blue towels, Kerlix, cautery tips, Glassman viscera container, KOH cup, instrument labeling tape, Jackson Pratt drain bulbs, Rainey clips, and, yes, a cell phone, and others). Even the newest radiofrequency identification and tracking systems would miss most of those items.
In addition to our many prior columns on RSI’s/RFO’s listed below, there are many good resources available to help prevent these. NoThing Left Behind® (NoThing Left Behind®) is the preeminent resource. Others include AORN (AORN 2018), the American College of Surgeons (ACS 2016), The Joint Commission (TJC 2017, TJC 2013), Pennsylvania Patient Safety Authority (Wallace 2017). Verna Gibbs,founder and director of NoThing Left Behind®, also recently provided some great tips for surgeons, nurses, and all OR staff for avoiding RSI’s (Gibbs 2019). And Victoria Steelman, another author of frequent publications on RSI’s, and her colleagues have also published recent articles on RSI’s (Steelman 2018, Steelman 2019)
Our prior columns on retained surgical items/retained foreign objects (RSI’s/RFO’s):
References:
TJC (The Joint Commission). Sentinel event statistics released for 2018. TJC Online 2019; March 13, 2019
TJC (The Joint Commission). Sentinel event statistics released for first 6 months of 2019 with new suicide categories. TJC Online 2019; August 14, 2019
CDPH (California Department of Public Health). Compleilnt Intake Number; CA00569261; CDPH 2019; Published June 18, 2019
CDPH (California Department of Public Health). Compleilnt Intake Number; CA00540695; CDPH 2019; Published January 16, 2019
CDPH (California Department of Public Health). Compleilnt Intake Number; CA00584143; CDPH 2019; Published January 18, 2019
NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items. Prevention of Retained Surgical Instruments
http://nothingleftbehind.org/Instruments.html
CDPH (California Department of Public Health). Event ID CA00235788
NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items
AORN (Association of periOperative Registered Nurses). Retained Surgical Items. 2018
ACS (American College of Surgeons). Revised statement on the prevention of unintentionally retained surgical items after surgery. October 1, 2016
TJC (The Joint Commission). New Sentinel Event Alert video: Preventing Unintended Retained Foreign Objects. Joint Commission Online 2017; October 25, 2017
TJC (The Joint Commission). Sentinel Event Alert. Preventing unintended retained foreign objects. Issue 51 October 17, 2013
http://www.pwrnewmedia.com/2013/joint_commission/urfo/downloads/SEA_51_URFOs.pdf
Wallace SC. PPSA (Pennsylvania Patient Safety Authority). Retained Surgical Items: Events and Guidelines Revisited. Pennsylvania Patient Safety Advisory 2017; 14(1): 27-35
http://patientsafety.pa.gov/ADVISORIES/Pages/201703_RSI.aspx
Gibbs V. 5 Keys to Preventing Retained Surgical Items. Use these strategies so there's nothing left behind. Outpatient Surgery 2019; XX(4): April 2019
Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Safety in Surgery 2018; 12:20 Published 29 June 2018
https://pssjournal.biomedcentral.com/articles/10.1186/s13037-018-0166-0
Steelman VM, Shah C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors. Joint Commission Journal on Quality and Patient Safety 2019; 45(4): 249-258
https://www.jointcommissionjournal.com/article/S1553-7250(18)30304-0/fulltext
Print “Yet Another (Not So) Unusual RSI”
August 27, 2019
Double Check on Double Checks
One of our most popular columns has been our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”. In that column we pointed out the lack of high-quality studies addressing the efficacy of double checks, though we continue to recommend them in certain circumstances, with the caveat that they are not infallible.
Even though we have emphasized that double checks are a relatively weak intervention (we also know from other industries that the error rate when a supervisor checks someone else’s work may be 10% or higher), the literature suggests a medication error reduction of about 30% when using a double check system (see our July 15, 2008 Patient Safety Tip of the Week “Heparin Flushes.....Again!”). Also, for many high-risk medications you need to do truly independent double checks (see our March 30, 2010 Patient Safety Tip of the Week “Publicly Released RCA’s: Everyone Learns from Them” for a description of independent double checks). Another nice article on independent double checks in preventing medication errors (ISMP Canada 2005) describes the independent double check process and calculates that independent double checks would reduce the error rate of a process having an error rate of 5% all the way down to 1 in 400.
Our January 2010 What’s New in the Patient Safety World column “ISMP Article on Double Checks” highlighted an article “Santa checks his list twice. Shouldn’t we?” that puts the independent double check process in perspective. They cite some studies done in community pharmacies that show double checks found errors in 2.6% to 4.2% of cases, about half of which were potentially significant. And the “average’ error checking rate is about 5%. But they also discuss how difficult it is for someone to pick up their own errors (because of phenomena such as confirmation bias) and point out that double checks work best when they are performed truly independently.
We’re now fortunate to have two timely articles on double checks within the past two months.
Koyama et al. (Koyama 2019) conducted a systematic review of studies evaluating evidence of the effectiveness of double checking to reduce medication administration errors. They identified thirteen studies but, of these, there were only two randomized controlled trials and one randomized trial in a simulated setting. The other 10 studies used an observational study design. Among three good quality studies, only one showed a significant association between double checking and a reduction in medication administration errors, another showed no association, and the third study reported only adherence rates. Also, it should be noted that no studies investigated changes in medication-related harm associated with double checking. They conclude that there is insufficient evidence that double versus single checking of medication administration is associated with lower rates of medication administration errors or reduced harm. They call for higher-quality studies to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required.
On the other hand, ISMP (ISMP 2019) published a very practical article on double checks. Though it notes the paucity of high-quality evidence on double checks, it summarizes findings from many of the observational studies that have demonstrated a benefit from correctly performed double checks. ISMP remains an advocate of truly independent double checks in special circumstances. Notably, it does not recommend them for all high alert medications. It cites the time-consuming nature of independent double checks as a downside.
ISMP suggests your decision about which processes should require an independent double check should be based upon analysis of 4 key considerations:
ISMP notes you might use findings from hazard and event analysis, or a FMEA (Failure mode and effects analysis) to help inform your decisions about what processes should require double checks. We’ve noted in our several columns on accidents with NMBA’s (neuromuscular blocking agents) that, if you store these in an automated dispensing cabinet, you need a way of verifying that the patient is intubated and ventilated (or that the NMBA is being used to facilitate intubation and ventilation) before dispensing the NMBA from the ADC. But we’ve also recommended that a second qualified healthcare professional verify that dispensing of the NMBA from the ADC is correct. But you need to be wary that the second person is truly acting independently and not simply ”signing off” complacently. How many times have you seen a transfusion reaction occur after two individuals supposedly “verified” the unit of blood was correct for that patient?
ISMP notes that bedside barcode verification may be more reliable than double checks for getting the correct patient, medication, and dose. But that independent double check at the bedside may be a better strategy for avoiding infusion pump programming errors and line confusion errors.
ISMP has always stressed that the double check needs to be a truly independent double check. That means that two qualified healthcare professionals need to assess the question(s) separately and only compare their conclusions after each has completed their assessments.
Both the ISMP and Koyama articles point out the considerable variation and often a lack of clarity about how the double check should be performed. They also note it is possible that double checking is never truly independent in real-world settings regardless of how the double-checking process is defined. For example, if the checker is “primed” in any way (as opposed to truly independent double checks), an error may not be detected due to confirmation bias.
ISMP reiterates the several themes from Armitage (Armitage 2008) that we discussed in our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?” that can lead to errors in the double checking process. These include:
ISMP adds another contributing factor: “satisficing” (failure to look for and process additional information once initial information looks correct).
Deference to authority occurs when the individual being asked to perform the double check perceives the first checker to be above them in the “hierarchy”. Note that sometimes it was the other person’s formal title or status that put them “above” in the hierarchy. For example, it could be the new hire double checking the work of an experienced worker. But at other times it was a perceived skill, often their ability to perform mathematical calculations rapidly, that put them in a position of authority!
Reduction or diffusion of responsibility refers to the complacency that tends to occur when someone feels that someone else will catch any mistakes that they made. We’ll actually take that a step further and note that we all have a tendency in the information age to think that “the computer says it’s ok so it must be ok”.
Distractions and interruptions might include social interactions and unrelated conversations that often interfere with the double checking process. The latter reminds us to use “the sterile cockpit” aviation concept, in which no extraneous conversation is allowed to occur during high risk activities such as takeoff and landing.
Auto-processing. An example of this might involve two people standing together with one reading item by item and the other simply nodding assent to each.
Lack of time is self-explanatory. But it also serves as a remined that, because the independent double check process is time-consuming, we need to use it only in those circumstances where it is most important.
In our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?” we mentioned use of checklists to help with the double check process. Indeed, checklists have been used successfully in the double checking process but there is a science to developing such checklists (White 2010). White and colleagues looked at the independent double checking process for administering outpatient chemotherapy medications. They used a very realistic simulation environment to observe nurses administering chemotherapy using two different checklists. While use of the two checklists did not differ significantly in detection of pump programming errors, there was a significant difference in the ability to detect other types of errors. They found that using very specific items, rather than more general warnings, significantly improved certain error types. For example, more errors occurred with a checklist that simply told them to check the medication label against the original order than with a checklist that specified the exact elements to check on the label and the order. Also, a general reminder to “think critically” and “remember the 5 rights” had virtually no impact. (We love the concept in John Nance’s book mentioned in our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!” where everyone always asks themselves “Could what I’m about to do cause harm to this patient?” but this article by White et al. would suggest that won’t actually have much of an impact). White et al. conclude that for independent double checking the most important factor is completion by the second individual of a well-designed checklist with specific items for each high-risk error. They provide a nice table of 7 important steps in developing such checklists.
The current ISMP article provides some good examples of questions that can be used in templates for double checks in some specific scenarios.
A very important point in the ISMP article is the need for standardization. It suggests that, to reduce inconsistencies, we should always establish a standard process for carrying out an independent double check and educate staff about its importance and how to carry it out properly. We must emphasize that it is not a superficial routine task or just a “cosigning” requirement. Rather, it is a significant independent cognitive task.
Finally, ISMP reminds us to avoid sole reliance on independent double checks.
We’d also like to point out the demise of another form of double check, the “mental” double check, in the era of computerized medicine. When we talk about double checks, we are usually talking about two separate individuals independently checking something. The mental double check may simply involve one person employing a separate cognitive process to double check. Or, it may be a nurse or pharmacist doing a quick mental double check of an order from a physician. In the “old days”, when a nurse looked at an order for a medication, he/she would do a quick mental calculation of the ordered dose and decide if the result fell into a reasonable range. In the era of CPOE and e-prescribing, it’s often assumed that whatever the computer says is correct and the step of “mental double checking” seems to be a lost art.
Some of our other columns on double checks:
January 2010 “ISMP Article on Double Checks”
October 26, 2010 “Confirming Medications During Anesthesia”
October 16, 2012 “What is the Evidence on Double Checks?”
December 9, 2014 “More Trouble with NMBA’s”
April 19, 2016 “Independent Double Checks and Oral Chemotherapy”
December 11, 2018 “Another NMBA Accident”
March 5, 2019 “Infusion Pump Problems”
References:
ISMP Canada. Lowering the Risk Of Medication Errors: Independent Double Checks. ISMP Canada Safety Bulletin 2005; 5(1): 1-2, January 2005
http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2005-01.pdf
ISMP. Santa checks his list twice. Shouldn’t we? ISMP Medication Safety Alert! Acute Care Edition 2009. December 17, 2009
https://www.ismp.org/resources/santa-checks-his-list-twice-shouldnt-we
Koyama AK, Maddox CS, Li L, et al. Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Quality & Safety 2019; Published Online First: 07 August 2019
https://qualitysafety.bmj.com/content/early/2019/08/07/bmjqs-2019-009552
ISMP (Institute for Safe Medication Practices). Independent Double Checks: Worth the Effort if Used Judiciously and Properly. ISMP Medication Safety Alert! Acute Care Edition 2019. June 6, 2019
Armitage G. Double checking medicines: defence against error or contributory factor? J Eval Clin Pract 2008; 14(4): 513-519
http://www.ncbi.nlm.nih.gov/pubmed/19133335
White RE, Trbovich PL, Easty AC, et al. Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. Qual Saf Health Care 2010; 19(6): 562–567
http://qualitysafety.bmj.com/content/19/6/562.full.pdf+html
Print “Double Check on Double Checks”
September 3, 2019
Lessons from an Inpatient Suicide
Our focus on preventing suicides in the hospital has dealt most often with events occurring on non-behavioral health units. But suicides occur more often on locked behavioral health units.
We just recently did a column on lessons from hospital suicide attempts (see our July 30, 2019 Patient Safety Tip of the Week “Lessons from Hospital Suicide Attempts”). But a recent suicide on a locked behavioral health unit has some additional lessons worth disseminating (OIG 2019). This case was particularly ironic, because it occurred at a VA hospital. The VA system has produced so many valuable resources on suicide prevention that we now use in hospitals world-wide. This unfortunate case had a variety of contributory factors that we know currently exist at many hospitals.
The Case
A patient was brought by police a hospital emergency department for an involuntary examination under state law after his spounse believed he was suicidal. He was placed on 1:1 observation and noted to be “visibly agitated and angry”. He was admitted to the locked inpatient behavioral health unit and was placed on “close” observation status and remained on that level of safety observation throughout the hospital stay. After a full suicide risk assessment the following morning, he was deemed to be at “high risk” of suicide. 23Throughout the course of the hospital stay, the patient was cooperative with staff and increasingly social with select unit peers. The patient engaged in most unit activities, was sleeping well, and had a good appetite. On the third hospital day he accepted initiation of antidepressant medication. He now denied suicidal thoughts and discharge was planned for the morning of the fourth hospital day. On the morning of day 4, his suicide risk assessment resulted in lowering his risk status to “low”. However, discharge was delayed contacts and arrangements for safe discharge were unsuccessful. Immediately upon learning of the delayed discharge, the patient became significantly agitated and began screaming and hitting the wall and his chest. After an hour he was calmer and resing in the room and told the nursing staff, "I will be all right, I just wanted to be discharged today." He denied suicidal ideation and was hopeful for discharge the following day.
A nursing assistant documented seeing the patient in his room around 5:45 p.m., when the patient also reportedly declined dinner due to not being hungry. The nursing assistant reportedly did not actually enter the patient’s room. At approximately 6:00 p.m., a peer patient went to the patient’s room to tell the patient there was a call on the public telephone in the day room. On reaching the room, the peer found the patient’s door was closed and noted resistance on the door when trying to open it. A nursing assistant went to the room and pushed the door to gain access. The nursing assistant found the patient, unresponsive, on the ground with a garment tied around his neck that was attached to another garment tied in a knot and wedged over the top of the door. A code was called and cardiopulmonary resuscitation was initiated but was unsuccessful.
The OIG Investigation
The case was reported to the Joint Commission as a sentinel event and facility leaders completed an institutional disclosure with members of the patient’s family. The VA Office of the Inspector General (OIG 2019) was called to formally investigate the case.
The OIG report did not find any significant problems with the patient’s assessments, treatment plans, or discharge plans. The report also did not find fault with the suicide risk status not being upgraded after the decision to delay discharge, given that he had become calm and denied suicidal ideation. However, the OIG found numerous problems related to the environment of care and the oversight of the unit and the process for assessing environment of care.
We’ve discussed the VA’s Mental Health Environment of Care Checklist (MHEOCC) in many columns (most recently in our January 29, 2019 “National Patient Safety Goal for Suicide Prevention”). We’ve also previously mentioned 2 publications (Watts 2016, Mills 2016) showing sustained results from implementation of the Mental Health Environment of Care Checklist (MHEOCC). The checklist and program became mandated at all VA hospitals in 2007. Inpatient suicide rates in VA hospitals dropped from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions from 2000 to 2015. The reduction in suicides coincided with introduction of the MHEOCC and has been sustained since implementation in 2007. Those authors stress that the physical changes brought about by the MHEOCC likely have a bigger impact on inpatient suicide reduction than the numerous other interventions used.
The hospital in the current case did apparently conduct MHEOCC risk assessment rounds on this behavioral health unit every 6 months in accord with the VHA policy. However, the Interdisciplinary Safety Inspection Team (ISIT) that conducts such assessment was found deficient in many respects. The OIG found that the hospital’s Facility Director failed to designate an ISIT to include the appropriate staff disciplines. The OIG team was told that neither an ISIT team nor a subcommittee had ever existed at the facility, and no minutes with the required elements had been recorded. While the facility did have an inspection team, the team was not comprised of the full range of appropriate disciplines and did not keep minutes.
VHA requires that MHEOCC training on environmental hazards should occur upon staff orientation and annually thereafter. Staff members who are both permanently assigned to the mental health unit or who have periodic responsibilities on the unit must be trained, including housekeepers, chaplains, outpatient providers, police officers, and members of the ISIT team. But the OIG found that only 44 percent of employees required to have the MHEOCC training completed the training in compliance with VHA Directive.
Responsible managers and staff who conducted Mental Health EOC rounds over the past three years either did not identify that bedroom doors (into the corridors) presented risks because they could be used as anchor points for hanging or that actions were required to mitigate those risks.
In our December 12, 2017 Patient Safety Tip of the Week “Joint Commission on Suicide Prevention” we noted that, in inpatient psychiatric units in both psychiatric hospitals and general/acute care settings, the doors between patient rooms and hallways must contain ligature-resistant hardware which includes, but may not be limited to, hinges, handles, and locking mechanisms. But other aspects of corridor doors on behavioral health units remain problematic. In our December 12, 2017 Patient Safety Tip of the Week “Joint Commission on Suicide Prevention” we noted that several panelists involved in The Joint Commission’s development of its suicide prevention standards reported that they were aware of cases in which a patient slipped a ligature between the corridor door and the door frame and/or hinges and committed suicide. And though there are several mechanical devices available to decrease the risk of the top of a door being used to fix a ligature (eg. laser beams, pressure-sensing plates, and monitoring cameras) they the efficacy of such devices is unproven. So, the panel did not recommend mandatory installation of such devices. Rather, they recommended organizations should note such doors on their environmental risk assessments and describe their mitigation strategies, such as appropriate rounding and monitoring by staff, requiring that doors be left open during certain hours, and so on. A previous VHA memorandum stated, “It continues to be important to monitor for environmental hazards and be aware that any sheet, piece of clothing, towel, or similar item can be used for hanging or strangulation and that many permanent fixtures do provide anchor points despite our efforts to eliminate them. Please consider the use of door alarms if you are not already using them.” Also, NCPS (VA National Center for Patient Safety) did not require the use of door top alarms, but suggested they be considered as a risk mitigation option (and these were included in slides developed by the VA in 2012). Over-the-door alarms use door top sensors to trigger an alarm in the nursing station when increased pressure (such as a ligature) is identified on the top of the door.
Security cameras had been installed several years earlier in response to a patient incident but had been rendered inoperative after they crashed the hospital’s network. They had never been re-deployed on a separate network and were, in effect, inoperative for several years. The facility’s Chief of Police told the OIG that cameras on this unit were “not required;” that “people rely too much on cameras;” and that “no camera in the world would have given a view” of the patient’s room. In fact, policy had required these cameras for several years following that previous incident.
The hospital’s routine protocol called for 15-minutes monitoring of patients. But the OIG report found several issues with compliance with that protocol. While unit staffing was sufficient on the day of the patient’s suicide, one of the nursing assistants assigned to conduct 15-minute safety rounds also performed other duties during that time contrary to protocol (nursing assistant drew blood on two patients and took vital signs while doing the 15-minute safety rounds). The nursing assistant also did not physically enter the patient’s room, instead communicating with the patient verbally through the door. The OIG report also found that observation could be done any time during the 15-minute interval, making it possible that patients could go as long as 25 minutes between checks.
Lastly, the OIG report came down heavily on leadership failures. The report notes that various facility leaders and managers knew, or should have known, about on-going lapses related to the unit physical environment, MHEOCC inspection rounds, staff training, the inoperative security cameras, etc.
The OIG report also noted that there had been a patient elopement from this unit just a few months earlier. The patient reportedly followed a housekeeper who exited the rear door of the unit. The facility’s review of that event identified several contributory factors, including the non-functional security cameras and the rear door’s distant location from the nursing station, as well as a lack of training for clinical and non-clinical staff that work on the unit. Sound familiar? Our July 30, 2019 Patient Safety Tip of the Week “Lessons from Hospital Suicide Attempts” described a similar case where a patient followed an administrative staff person and reached an exit door as it closed but before it fully closed and locked. He was observed peering through the door window and then entering the outer corridor. He subsequently jumped 30 feet to a concrete patio, suffering multiple traumatic injuries. The administrative staff person had never been oriented to the behavioral health unit and never received specific training on making sure the unit locked doors were secured when going in and out and there was no formal policy for such orientation.
There were 50 suicides reported to The Joint Commission as sentinel events in 2018 (TJC 2019a) The Joint Commission (TJC) noted that approximately 425 suicides within healthcare settings had been reported as sentinel events over the previous five years (TJC 2017). In 2019, the Joint Commission has split out suicides occurring on inpatient units, emergency departments, and off-site within 72 hours of discharge (including discharge from the ED). There have been 21 inpatient suicides reported as sentinel events in the first half of 2019 (TJC 2019b). VA facilities reported 37 inpatient suicides from 2012 through 2017, including two on locked mental health units, to the VHA National Center for Patient Safety (NCPS). (OIG 2019).
Hanging is the method used in more than 70 percent of inpatient suicides, as independently reported by the Centers for Disease Control and Prevention’s National Violent Death Reporting System, TJC’s Sentinel Event Database, and VHA’s NCPS. Using the VA’s Mental Health Environment of Care Checklist (MHEOCC) is critical for finding hazards for suicide in the environment, but obviously you need to use it religiously and follow up promptly on deficiencies you identify. See also our Patient Safety Tips of the Week for December 12, 2017 “Joint Commission on Suicide Prevention” and January 29, 2019 “National Patient Safety Goal for Suicide Prevention” for all the Joint Commission standards and expectations. The current case, though, should make you strongly consider whether you need to install over-the-door alarms (or equivalent devices) on the corridor doors on your inpatient behavioral health units.
To review lessons learned here:
And though our focus here has been on prevention of inpatient suicides, we’d be remiss if we did not mention two extremely valuable contributions to the outpatient assessment and management of patients at risk for suicide, just published in the Annals of Internal Medicine (Sall 2019, D'Anci 2019).
Some of our prior columns on preventing hospital suicides:
Some of our past columns on issues related to behavioral health:
References:
OIG (Office of Inspector General). Department of Veterans Affairs. VHA (Veterans Health Administration). Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center Florida. Healthcare Inspection Report #19-07429-195; August 22, 2019
https://www.va.gov/oig/pubs/VAOIG-19-07429-195.pdf
Mental Health Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
TJC (The Joint Commission). Sentinel event statistics released for 2018. TJC Online 2019; March 13, 2019
TJC (The Joint Commission). Sentinel event statistics released for first 6 months of 2019 with new suicide categories. TJC Online 2019; August 14, 2019
VA National Suicide Data Report 2005-2016; Office of Mental Health and Suicide Prevention, September 2018
TJC (The Joint Commission). Special Report: Suicide Prevention in Health Care Settings. Joint Commission Perspectives 2017 Nov; 37(11): 1, 3-7
https://www.jointcommission.org/assets/1/6/November_Perspectives_Suicide_Risk_Reduction.pdf
Sall J, Brenner L, Bell AMM, Colston MJ. Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med 2019; [Epub ahead of print 27 August 2019]
D'Anci KE, Uhl S, Giradi G, Martin C. Treatments for the Prevention and Management of Suicide: A Systematic Review. Ann Intern Med 2019; [Epub ahead of print 27 August 2019]
Print “Lessons from an Inpatient Suicide”
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
In our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” we noted Joint Commission’s new requirement for newborn naming (TJC 2018). The convention required use of two distinct methods of identification for newborn patients. You need distinct naming conventions using the mother's first and last names and the newborn's sex (for example, "Smith, Judy Girl" or "Smith, Judy Girl A" and "Smith, Judy Girl B" for multiples). You also need standardized practices for identification banding (for example, two body-site identification and bar coding). You also need to establish identification-specific communication tools among staff (for example, visually alerting staff with signage noting newborns with similar names).
That new requirement was effective January 1, 2019. But already there have been two publications citing errors related to that new requirement.
ISMP (ISMP 2019) received several reports of errors from hospitals that have implemented this change. Most of these reported mix-ups have been between the mother and newborn, rather than between different newborns with similar names. Concerns have been that TJC newborn naming convention makes the mother’s and newborn’s names too similar.
In one example given, Rho immune globulin intended for the mother instead appeared as an order for the infant. In another, surfactant intended for the infant appeared as an order for the mother. Fortunately, in both cases the error was discovered before the drugs were actually administered to the wrong patient. In another example, it was unclear whether an order for an EKG was for the mother or infant.
In yet another hospital, the long length of a mother’s last and first names led to truncation of the names on bracelets of newborn identical twins, leading to identical names on the both infants’ bracelets and on the mother’s bracelet. The result was that both newborns had the same identifying name, which was also the same as their mother’s name.
Also, truncation of names on EHR screens could lead to misidentification between mother and newborn.
In other error examples, confusion arose when pharmacists knew the actual given names for the newborns and used those for orders for parenteral nutrition (PN), which was an outsourced product. The EHR order used the TJC convention for naming. So, there was difficulty matching the name on the label for the outsourced product with the name on the EHR order.
While the ISMP reports found errors mostly between mother and newborn, Jason Adelman and colleagues, whose work on patient identification errors we’ve highlighted in so many columns, were concerned that names in the new TJC convention might be too similar in cases of multiple births (essentially differing only by one digit). So they did a study (Adelman 2019) which confirmed that multiple-birth infants had a higher risk of wrong-patient order errors compared with singleton babies in the neonatal intensive care unit (NICU). Twins, triplets, and higher-order multiples had a significantly higher risk of wrong-patient order errors compared with singleton births (adjusted odds ratio 1.75).
Their study was a retrospective one in 6 NICU’s that used distinct temporary names for newborns per the requirements of The Joint Commission. They used the Wrong-Patient Retract-and-Reorder (RAR) Measure, which we’ve discussed in several of the patient misidentification columns listed below. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes.
The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75). The rate of “extrafamilial” RAR events among multiple-birth infants was similar to that of singleton-birth infants (36.1 vs. 41.7 per 100 000 orders, respectively). But the excess risk among multiple-birth infants (29.9 per 100 000 orders) appeared to be owing to “intrafamilial” RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births.
Infants in NICU’s are especially prone to misidentification errors. Previous work by Adelman et al. had shown wrong-patient errors were more common in NICU patients than in non-NICU pediatric patients (Adelman 2017). In several columns we’ve noted the work of Gray et al. (Gray 2006), who found multiple patients with the same last names on 34% of all NICU days during a full calendar year, and similar sounding names on 9.7% of days. When similar appearing medical records numbers were also included, not a single day occurred where there was no risk for patient misidentification.
Wrong-patient errors in neonatal nurseries and NICU’s most often involve medication errors but occasionally also result in wrong procedures. Could they result in switched babies (recall our November 17, 2009 Patient Safety Tip of the Week “Switched Babies”) or breast milk mixups (see our April 8, 2014 Patient Safety Tip of the Week “FMEA to Avoid Breastmilk Mixups”)? A recent near-miss (Colgrove 2018) illustrates how such an accident might happen. A father with the last name Perry went to get his newborn son out of the nursery. "The boy was sitting in the same spot," Perry said. "He had a card that said Perry. It didn't have height or weight or anything on the card. He had sandy blonde hair and was rolled up. He looked like my baby." He says his baby had been in a cart labeled 204, and this baby was in cart 205. Perry said 'This is my baby, why is he in the wrong cart?' The nurse said someone must have messed up," "She went and marked it (205) out and put 204. I rolled the baby on down there." For about 2 hours, family and relatives held the newborn and took pictures, not realizing it was the wrong baby. They say a nurse came into their room and checked the baby's armband number, and then the nurse came back later with their real son. Perry says the family became distraught when they realized what had happened. "They were crying, upset, couldn't believe it, scared," Perry said.
In the editorial accompanying the current Adelman study, Freed (Freed 2019) notes that the “excess risk was almost exclusively attributed to errors among siblings and not other, unrelated infants in the NICU. Additionally, the risk increased with the number of siblings an infant had in the NICU. Adding to the strength of their findings was that the elevated risk of wrong-patient errors for siblings was consistent across institutions, electronic medical record systems, and patient populations.” He notes that well-intentioned patient safety interventions can have unexpected and unintended consequences unless we are careful to assess the impact of such changes.
Adelman et al. propose alternate strategies that may mitigate the risk of newborn misidentification, particularly among multiple births. First, they propose that hospitals use the newborn’s given name, when available, or use a pseudonym when the newborn’s given name is not yet chosen or when cultural or religious beliefs preclude its use. On return for care after hospital discharge, the pseudonym will be changed according to the infant’s birth certificate.
Second, they propose that hospitals switch from the temporary name to the given name as soon as it becomes available if the infant is admitted to the NICU, with the caution that systems interoperability should be tested and any issues should be addressed.
Third, they propose that obstetricians consider approaches to encourage parents, particularly of multiple gestation pregnancies, to select names or pseudonyms to use at birth, while respecting parents’ cultural and religious practices.
They stress that implementing these solutions would require changes to health information technology systems, workflows, and training, with the potential for additional costs and unintended consequences.
Both the ISMP and Adelman articles are stark reminders that unintended consequences pop up after even our most well-intended solutions to problems. Whenever we implement new interventions, it is imperative that we plan for assessing the impact of those interventions, whether positive or negative. That is why we consider the most important of the three quality improvement questions we always ask is “How will we know we improved {problem x}?”.
Some of our prior columns related to identification issues in newborns:
November 17, 2009 “Switched Babies”
December 20, 2011 “Infant Abduction”
September 4, 2012 “More Infant Abductions”
December 11, 2012 “Breastfeeding Mixup Again”
April 8, 2014 “FMEA to Avoid Breastmilk Mixups”
August 2015 “Newborn Name Confusion”
January 19, 2016 “Patient Identification in the Spotlight”
July 19, 2016 “Infants and Wrong Site Surgery”
August 1, 2017 “Progress on Wrong Patient Orders”
March 26, 2019 “Patient Misidentification”
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
TJC (The Joint Commission). Distinct newborn identification requirement. R3 Report 2018; Issue 17, June 25, 2018
https://www.jointcommission.org/assets/1/18/R3_17_Newborn_identification_6_22_18_FINAL.pdf
ISMP (Institute for Safe Medication Practices). What’s in a Name? Newborn Naming Conventions and Wrong-Patient Errors. ISMP Medication Safety Alert! Acute Care Edition 2019; April 25, 2019
https://www.ismp.org/resources/whats-name-newborn-naming-conventions-and-wrong-patient-errors
Adelman JS, Applebaum JR, Southern WN, et al. Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems. JAMA Pediatr 2019; Published online August 26, 2019
https://jamanetwork.com/journals/jamapediatrics/article-abstract/2748683
Adelman JS, Aschner JL, Schechter CB, et al. Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU. Pediatrics 2017; 139(5): e20162863
https://pediatrics.aappublications.org/content/139/5/e20162863
Gray JE, Suresh G, Ursprung R, et al. Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 2006; 117: e43-e47
http://pediatrics.aappublications.org/cgi/reprint/117/1/e43
Colgrove A. Family says they were given wrong baby at Logan hospital. WSAZ.com 2018; June 19, 2019
https://www.wsaz.com/content/news/Family-says-they-were-given-wrong-baby--485986031.html
Freed GL. When New Standards to Improve Safety Do Not Actually Improve Safety. JAMA Pediatr 2019; Published online August 26, 2019
https://jamanetwork.com/journals/jamapediatrics/article-abstract/2748678
Print “Joint Commission Naming Standard Leaves a Gap”
September 17, 2019
ACS Geriatric Surgery Verification Program
The American College of Surgeons (ACS) has developed a Geriatric Surgery Verification Program, aimed at improving surgical care and outcomes for the aging adult population.
The GSV Program provides hospitals with a validated list of 30 evidence-based and patient-centered standards for geriatric surgery that hospitals can implement to continuously optimize surgical care for this vulnerable population (ACS 2019). The standards were developed by the ACS in conjunction with over 50 stakeholder organizations, with support from the John A. Hartford Foundation.
Hospitals can formally enroll in the GSV program this October at the 2019 ACS Clinical Congress in San Francisco.
Hospitals must submit a letter of commitment from their CEO and demonstrate they have a Geriatric Surgery Director, Geriatric Surgery Coordinator, and Geriatric Surgery Quality Committee (roles of each are explained in the ACS document).
There is a requirement for geriatric-friendly patient rooms, which must include space for family and caregiver visitation and include directed elements for patient reorientation (for example, large clock or other display of date, day, and time; daily planned activity goals; any anticipated medical tests or procedures; names of care team; and so on). If space for visitation cannot be provided within the patient room, there must be an alternative communal visiting area.
Each surgical floor must have at least one Geriatric Surgery Nurse Champion (GSNC), whose responsibilities include not only leadership but also responsibility for nursing education, quality improvement, and continuing education.
Shared decision making is a key component of the standards. Deliberation over surgical decision making must allow older adults the opportunity to discuss the following with the surgeon:
After discussion, the surgeon needs to document the treatment plan and how it has been informed by shared discussion of the patient’s goals. Patient health goals relative to the surgical condition can be categorized broadly into (1) prolonging life, (2) preserving function or independence, (3) relieving symptoms, (4) curing a condition, or (5) establishing a diagnosis. Older adults should have the opportunity to identify an overall health goal that is personal and specific, such as “I want to be able to walk at my grandson’s wedding this summer.” This standard aims to distinguish between overall health goals and treatment goals specific to the current condition. Though overall health goals and health care treatment preferences are often aligned, this is not always the case; this standard aims to improve that alignment
Another standard is that code status and any existing advance directive must be reviewed preoperatively by the surgeon. Patients without a defined code status or an advance care plan must be offered the opportunity to establish an advance directive in addition to being provided with educational resources on advance care planning. All patients must have a health care representative, surrogate, or proxy identified with name and contact information clearly documented. For those without, there must be documentation of an effort to identify one. Educational materials must be provided to facilitate discussion between the patient and his or her surrogate about the patient’s overall health and treatment goals.
For patients with anticipated admission to the intensive care unit (ICU), there must be a discussion regarding the indications for, limitations of, and patient’s desire for life-sustaining treatments, including issues such as cardiopulmonary resuscitation, mechanical ventilation, feeding tubes, hemodialysis, and blood transfusion. These might be discussed as part of a standard anesthesia visit or preoperative admission process.
The patient and family/caregiver(s) must be offered the opportunity to reaffirm the initial surgical decision making, by an in-person visit, a telephone call, or a telehealth visit with surgical staff or a designated representative.
The standards put an important focus on the preoperative evaluation. Patients must be screened for the following high-risk characteristics to identify potential areas of vulnerability:
We are very pleased to see the focus on identifying delirium risk and the several factors that contribute to frailty. Moreover, the standards call for a documented management plan directed at positive findings from the screens.
In the elective setting, all patients identified as high risk based on the geriatric vulnerability screens must be evaluated with interdisciplinary input after the implementation of focused management plans and before surgery to reassess the indications, risks, and benefits of the proposed operation. This may be conducted in the form of an interdisciplinary conference or by obtaining input from at least the following health professionals:
Interdisciplinary conferences should arrive at documentation of a consensus treatment recommendation and ensure communication of recommendations to patients and their families/caregivers and other clinicians responsible for the care of the patients.
A very important point is that, for patients at high risk, the surgeon or surgeon’s representative must communicate the goals of care and decision-making discussion to the patient’s preferred primary care provider (PCP) or the provider designated by the patient as his or her “main doctor.”
Multiple standards apply to post-operative care. There is an emphasis on ensuring that patients’ personal sensory equipment (glasses, hearing aids, dentures, etc.) are collected and returned to the patient immediately postoperatively. We’ve discussed the importance of this in our many columns on preventing and managing delirium.
There must be processes, protocols, or policies in place to assess for and alert providers to the use of potentially inappropriate medications, using tools such as Beers Criteria®. The ACS suggests use of standardized order sets/bundles/pathways to protocolize medication management for geriatric patients or use of templated order sets with Beers medications removed and alternatives provided. Hospitals should also have ways for flagging and reviewing inappropriate medications when they are ordered (eg. daily pharmacy reviews, embedded decision support tools within the electronic health record that provide alerts when a potentially inappropriate medication is prescribed). They also stress provider education identifying surgically relevant Beers medications along with alternatives available within institutional formulary
They stress opioid-sparing, multimodality pain management for all postoperative patients. That includes opioid-sparing techniques like use of regional analgesia and use of pre-, intra-, or postoperative non-opioid analgesics. But it also stresses avoidance of other potentially inappropriate analgesics as defined by the AGS Beers Criteria, appropriate titration of medications for the increased sensitivity and altered physiology of the older adult, prophylactic pharmacologic bowel regimen, and use of non-medication-based strategies for pain control.
Standards really focus on prevention, identification, and management of postoperative delirium. There should be daily screening with a validated tool such as the CAM (confusion assessment method). Identifying and treating or discontinuing precipitating factors through non-pharmacologic and pharmacologic interventions (eg. correcting electrolyte derangements, treating infections, minimizing tethering devices, etc.) is important. There also needs to be attention to mobility, with a goal of ambulation or non-ambulatory mobilization by postoperative day one, fall prevention, daily evaluation of need for tethering devices, and daily assessment of pressure ulcer risk and skin integrity. Other factors needing special post-operative attention are nutrition and hydration (preferably via the enteral route), a bowel regimen (especially for those requiring opioid pain medications), and aspiration precautions (eg. elevated head-of-bed, upright post-prandial positioning). The above issues may be addressed through pathways, bundles, order sets, protocols, or a combination thereof.
The standards call for interdisciplinary care for all patients identified as high risk based on the geriatric vulnerability screens. Initial postoperative care must be provided by interdisciplinary health care professionals, including but are not limited to:
Recommendations by participating members of the interdisciplinary team must be documented daily.
Goals of care must be revisited when an older adult experiences an unexpected escalation of care to the ICU and must be readdressed at least every three days for all ICU patients.
Planning for discharge or other transitions of care is critical. All patients must undergo geriatric vulnerability screens at discharge to assess for changes in vulnerability during their hospital stay. An appropriate plan of action to address identified deficits must be documented in the medical record as part of the discharge documentation. Geriatric vulnerabilities to especially be assessed at discharge include impaired cognition. delirium risk, impaired functional status, impaired mobility, and malnutrition. Discharge documentation should also specifically identify any deficits discovered on pre-discharge screens along with the plan of action to address each vulnerability. Information regarding common geriatric syndromes, including risk factors for functional decline, falls, delirium, and how to respond to each if it occurs after discharge should be included. The contents of the discharge summary must be discussed with the patient and/or his or her caregiver, and a copy must be provided to:
There must be a process, protocol, or policy in place addressing the communication structure between the institution and post-acute care facilities.
The standards also include collection and review of data for all patients included within the scope of the GSV Program. Data must be reviewed at least quarterly by the GSQC to identify, trend, and address issues specific to geriatric surgical care. The GSV document discusses the metrics to review and the need for a process, protocol, or policy in place for feedback of the data collected and reviewed. The SV program mandates at least one quality improvement (QI)/performance improvement (PI) project annually pertinent to geriatric surgical care informed by the data collected and reviewed by the GSQC.
The standards go on to discuss other potential quality improvement collaborative opportunities and to discuss the ongoing educational requirements and recommendations for physicians, nurses, and other healthcare professionals. Also required is a community outreach project focused on issues pertinent to geriatric surgical care, and it must be conducted at least annually. This project may take the form of awareness, prevention, or education. The GSV also strongly urges participation in research or work toward advancement of geriatric surgical knowledge and care.
Many of the standards are also in keeping with a findings of a recent study on factors that lead to successful care of older patients on medical wards (Baxter 2019). Those researchers hypothesized there were 14 care team factors that contributed to patient safety on the wards:
They focused on five characteristics that healthcare professionals considered to be most salient in successful care of older patients. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of successful wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented.
The findings of the Baxter study mesh well with the GSV focus on teamwork and interdisciplinary collaboration in caring for the older surgical patient.
One other program we’ve previously mentioned is the American College of Surgeons’ Strong for Surgery program. That program is intended for all surgical patients, but its components are equally applicable to the older surgical patient. This program is intended to optimize patients’ overall status prior to surgery and provides a toolkit with checklists. “Strong for Surgery” empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. The checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes.” The checklists in the Strong for Surgery Toolkit target eight areas known to be influential determinants of surgical outcomes:
There’s no reason the concepts from the ACS Strong for Surgery program cannot be used in conjunction with the new ACS Geriatric Surgery Verification Program,
References:
ACS (American College of Surgeon). Geriatric Surgery Verification Quality Improvement Program. Optimal Resources for Geriatric Surgery2019 Standards. ACS 2019
https://www.facs.org/-/media/files/quality-programs/geriatric/geriatricsv_standards.ashx?la=en
Baxter R, Taylor N, Kellar I, et al. A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people BMJ Quality & Safety 2019; 28: 618-626
https://qualitysafety.bmj.com/content/28/8/618
ACS (American College of Surgeons). Strong for Surgery. Updated November 2018
https://www.facs.org/quality-programs/strong-for-surgery
Print “American College of Surgeons Geriatric Surgery Verification Program”
September 24, 2019
EHR-related Malpractice Claims
Malpractice claims related to electronic health records (EHR’s) are beginning to appear more and more. We’ve done multiple columns on the unintended consequences of and the errors related to healthcare IT, so it should be no surprise that some of these may result in malpractice claims.
Two recent papers illustrate the problems. Graber and colleagues (Graber 2019) analyzed 248 cases involving health IT submitted to the CRICO claims database during 2012 and 2013. Ambulatory care accounted for most of the cases (146 cases). Medications (31%), diagnosis (28%), or a complication of treatment (31%) were the most frequently involved categories. More than 80% of cases involved moderate or severe harm, although lethal cases were less likely in cases from ambulatory settings. Etiologic factors spanned all of the sociotechnical dimensions, and many recurring patterns of error were identified.
63% of cases involved user-related issues and 58% involved technology-related issues. In many cases, more than one contributing factor was identified.
Ranum (Ranum 2019) analyzed The Doctors Company’s claims in which EHR’s contributed to injury. There was a total of 216 claims closed from 2010 to 2018. EHRs were typically contributing factors rather than the primary cause of claims, and the frequency of claims with an EHR factor continues to be low, accounting for 1.1 percent of all claims closed since 2010 (claims in the Graber study above also accounted for less than 1% of all claims).
As you’d expect, errors related to medications or test results tend to be most frequent, reflecting the relative frequency with which these are dealt by EHR’s. Also, those are two categories likely to be related to the more serious types of error that would lead to a malpractice claim, such as missing or delaying a diagnosis of cancer.
Both papers break down the EHR contributions as either system-related or user-related.
System-related issues include things like EHR’s being down or crashed, inability to access certain parts of the medical record, having data in fields other than where the physician expected it, routing issues, and others. In one case the EHR automatically “signed” a test result when in fact it had not been read.
Poor system design
Both studies provide multiple examples of errors leading to or contributing to claims. As you’d expect, the “cursor” error (also known by other names like juxtaposition error), that we’ve discussed so often, contributed in many cases. This is where one clicks on an item in a drop-down list that is adjacent to the item one actually intended to click. That may result in choosing the wrong medication or a wrong dose or even a wrong route of administration.
One example in the Graber paper was an otolaryngologist intending to order Flonase, instead choosing Flomax from a drop-down menu. Interestingly, the Ranum paper also had a case where a physician entered “FLO” and a list stopped at FLOMAX, which was not the intended drug. Another case in the Ranum paper was a physician ordering morphine but clicking on the wrong dose in a drop-down menu, resulting in an opioid overdose.
While some would ascribe these errors to “human” error or user-related error, we consider the root cause of these to be poor design of systems. It should be recognized that your typical user of almost any computer or smart phone probably makes cursor errors every day, clicking on an item other than the one intended. While the user recognizes this in most cases, a few slip by.
It’s surprising to us that there were not more instances of truncation errors. In many of our columns on wrong patient errors, we’ve noted that some EHR lists may truncate the full name of patients or show lists that stop above other patients having the same name. The Ranum paper had the case noted above where a physician entered “FLO” and a list stopped at FLOMAX, which was not the intended drug.
We are also surprised they did not find cases of patient misidentification due to having multiple individual patient records open at the same time.
Yet other cases had to do with failure to see important information. Examples included instances where a test result was “signed” as read even though no one had actually seen the result.
Cases where good clinical decision support tools could help
There were cases where good clinical decision support tools could help. For example, in some cases, programming in a “usual” dosage range might have prevented an overdose of a medication. That might be especially useful in cases of “missed” decimal points.
Graber et al. also note good CDSS could detect that an order for potassium in a patient already hyperkalemic is probably inappropriate.
Lack of access to the EHR
Others had to do with the IT systems being down or crashing, resulting in lack of access to important clinical information.
Routing issues
Graber et al. “encountered repeated examples of laboratory results going to the wrong provider, documentation not being available to the providers who needed it, and assorted other problems of getting the right data to the right provider.” We’ve found that this is especially a problem when there are changes of attending physician, housestaff changes, or changes of service (eg. from surgery to medicine). We’ve also often seen EHR fields used for things other than their intended use. For example, typical hospital EHR’s have a field for the patient’s primary care physician (PCP). But changes in PCP are often not updated in the hospital EHR. Moreover, we’ve often seen hospitals use that field for other purposes (such as for the emergency physician or the inpatient attending or a consultant).
Interoperability issues
Interoperability issues also played a role in some cases. For example, results of a study available on one system may not have been available on another system. Some involved lack of integration between an office system and a hospital system.
The “hybrid” medical record
Medical record systems that include both paper and electronic records are particularly vulnerable. Some errors occurred during conversion from paper records to the EHR. For example, a pediatric patient received an antibiotic to which he/she was allergic. The allergy was documented in the paper record but not uploaded into the EHR. Hybrid systems (where some records are in paper form, others in electronic form) are especially vulnerable. The Graber study found these instances were more common in ambulatory care and occurred when both paper and electronic systems were in use at the same time, or during a transition from paper to electronic, or one EHR to another.
Field mapping issues
In some cases, information got entered into fields or sections of the EHR other than where the clinician expected to find it. For example, a positive test result for cervical cancer was entered into the problem list rather than the results section, where the clinician expected to find it. In some cases, that may be due to inconsistencies when “mapping” fields for transmission of data items from one system to another.
Tests pending at discharge
One of the cases noted by Graber et al. involved a Pathology report of adenocarcinoma that was delayed in reaching a patient's chart until after inpatient discharge and no alert was sent to the patient's physician, resulting in the delayed diagnosis of cancer. See our multiple columns, listed below, on both tests pending at discharge and communication of significant findings.
Every year we see cases where the diagnosis of cancer is missed or delayed because test results showing the cancer were never seen by a responsible physician. Often, a patient is cared for in a hospital by someone (for example, a hospitalist or an academic service team) who will never see that patient again after discharge. Hence, it is critical that the message that there are pending test results be conveyed to the appropriate physician who will be providing follow up care for that patient.
We’ve made a strong case for always including in every discharge summary a section for “test results pending”. We also noted in our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks” that studies have shown sending reports to two physicians, rather than increasing the likelihood someone will follow up, actually doubles the risk that no one will follow up (Singh 2009)!
But even identifying test results pending can be difficulty, particularly in patients with prolonged hospital lengths of stay. In such cases, hospitalists or academic teams may change during the course of that hospital stay and the oncoming physician(s) may not realize which tests have been done without results reported.
That’s why hospital labs and radiology departments need to have policies and protocols in place for ensuring that significant test results (such as those suggesting cancer) are communicated to the appropriate physician.
User-related issues include, among other issues, how clinicians enter data into the EHR or how they interact with alerts.
Copy & paste
No surprise here. In one case, a note copied and pasted from a previous note did not include a critical medication that had been added later. In another case, a crucial progress note was identical to the previous note from three months earlier, including old vital signs and spelling errors.
Copy & paste errors often led to medication errors, sometimes copying over a medication that had been discontinued since the prior note, and sometimes failing to include a medication that had been started since the prior note. For example, Graber et al. noted a case where a history copied from a previous note, which did not document patient's amiodarone medication; delayed recognition of amiodarone toxicity.
Pre-population of fields
Many EHRs auto-populate fields in the patient’s history and physical exam and in procedure notes, sometimes causing the entering of erroneous or outdated clinical information.
And, while it is not mentioned in either of the current papers, a new study raises a serious question of an issue closely related to the copy & paste and pre-population issues. Berdahl and colleagues (Berdahl 2019) compared documentation in the EHR to what was actually observed being obtained by emergency department residents. The disparity between electronic clinical documentation and physicians’ observed behavior was quite striking. For ROS (review of systems), physicians documented a median of 14 systems, while audio recordings confirmed a median of 5 systems. Overall, only 38.5% of documented ROS systems were confirmed by audio recording data. For PE (physical examination), resident physicians documented a median of 8 verifiable systems, while observers confirmed a median of 5.5 systems. Overall, only 53.2% of verifiable documented PE systems were confirmed by concurrent observation. The authors speculate whether pressures to maximize billing might be driving this phenomenon and make a case for payers to consider removing financial incentives to generate lengthy documentation.
Obviously, from a patient safety perspective, the presence of incorrect information in the EHR be a serious safety vulnerability, especially since that information is likely to be propagated forward. And from a malpractice perspective, lawyers could have a heyday when they discover totally erroneous information in the EHR that would call into question the validity of everything done on that patient. In the accompanying editorial, Jetté and Kwon (Jetté 2019) note that unsubstantiated documentation was more common for elements that seemed to be less clinically relevant. But, imagine what lawyers might do in a claim about a diagnostic error when they find a field in the EHR that states “dorsalis pedis pulse 2+ bilaterally” in a double amputee! Even though that might have zero relevance to the actual claim, the lawyers would question the validity of everything else in that EHR and impeach everything used by the defending physician.
Overriding alerts
In one example, a physician overrode an alert that the patient was allergic to the drug ordered. We’d expect this may be the category that would be most difficult to defend. We know that very large percentages of alerts are ignored or overridden and that alert fatigue is a huge issue. That is why design of alerts is such a critical function. Sometimes there are good reasons for overriding an alert but, unless there is a “hard stop” associated with that alert, most systems do not allow a physician to enter a reason for overriding the alert. This vulnerability is another good reason to keep the use of alerts to a minimum and offer the clinician the opportunity to provide a reason for the alert override.
Training/education
Training/education were also important. There was one case where a covering physician had not been adequately trained to use the EHR and did not have a password. In another, the physician expected to see a paper copy of a CT scan report and the report only went to the EHR.
While we all invest in education and training at initial rollouts or updates of EHR’s, we need to be particularly wary about the need to orient, educate, and train those clinicians who enter the organization at other times. That may be a new resident rotating through a hospital, a new hospital staff attending, a locum tenens physician, an “agency” nurse, or a hospitalist or emergency physician filling in a gap for another physician.
The Ranum paper also includes several useful videos. One deals with the cut & paste isse and another with the pre-populated data issue. The third talks about the need for “audit, backup, and cross check”
One way we found useful to avoid missing test results was to create a field in the EHR in which we put all tests ordered. Once a result of that test was received and reviewed, we would remove that test from the “test pending” field. You can create a search to perform weekly (or at other appropriate interval) that is something like {find all my patients in whom the “test pending” field is not empty}. Including the date a test was ordered can also help make your searches produce more specific results. For example, your search might be {find all cases in which a Pap smear ordered more than 2 weeks ago has not yet been resulted and reviewed}. This can also help you identify those instances where you recommended a test and the patient did not follow up and get the test. Note: you have to make sure your EHR allows such a “temporary” field where you can add and remove text without illegally “altering” the medical record. The other method would be to have a field that lists all the tests with 2 checkboxes, one that gets checked when a test/study is ordered and one that gets checked when the test has been done and the report has been reviewed. Then your search could be {find any tests ordered but not yet reviewed}.
The Ranum paper also reminds us that a patient injury may result from a failure to access or make use of available patient information. It also reminds us that EHR metadata documents what was reviewed. So, you might have a tough time in court claiming you saw certain data in the EHR, when the metadata shows you didn’t.
While some errors are due to poor design of systems and others to “human” factors, more errors are related to the way humans interact with technology. It should not be surprising that we will continue to see both adverse patient events and malpractice claims related to those interactions. But that doesn’t mean we can’t fix some of our systems to minimize the chances of such errors. You’ll find it worthwhile for your clinical and IT staffs, plus your risk management staffs, to look at the two papers reviewed in today’s column. Reviewing any malpractice claims in your organization and any RCA’s you’ve done after adverse events may also identify EHR-related issues you need to address. You’ll also find many issues in our columns, listed below, on the unintended consequences of technology.
See also our other columns on communicating significant results:
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Graber ML, Siegal D, Riah H, et al. Electronic Health Record–Related Events in Medical Malpractice Claims. Journal of Patient Safety 2019; 15(2): 77-85
Ranum, D. Electronic Health Records Continue to Lead to Medical Malpractice Suits. The Doctor Company 2019
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/224747
Berdahl CT, Moran GJ, McBride O, Santini AM, Verzhbinsky IA, Schriger DL. Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior. JAMA Netw Open 2019; 2(9): e1911390 Published online September 18, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751388
Jetté N, Kwon C. Electronic Health Records—A System Only as Beneficial as Its Data. JAMA Netw Open 2019; 2(9): e1911679 Published online September 18, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751386
Print “EHR-related Malpractice Claims”
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
Click on the "Contact Us" button at the left to send us your comments on our "Patient Safety Tip of the Week" cases.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
January 31, 2023
January 24, 2023
January 17, 2023
Patient Safety with NOAC’s and DOAC’s
January 10, 2023
January 3, 2023
Helping Inpatients Sleep – Failing Grades
December 27, 2022
Tip of the Week on Vacation
December 20, 2022
Amazing Results from I-PASS Implementation
December 13, 2022
Surgical Teams – the “Consistency Score”
December 6, 2022
Rare Risk – Defibrillator Fires
November 29, 2022
November 22, 2022
The Apple Watch and Patient Safety
November 15, 2022
November 8, 2022
November 1, 2022
APSF on Criminalization of Medical Error
October 25, 2022
October 18, 2022
Methotrexate Again, With a Twist
October 11, 2022
Good Intentions, Unintended Consequences
October 4, 2022
Successfully Reducing OR Traffic
September 27, 2022
September 20, 2022
September 13, 2022
Smart Socks and Robots for Fall Prevention?
September 6, 2022
AORN and Others on Retained Surgical Items
August 30, 2022
August 23, 2022
Yes, There is a Proper Way to Assess Orthostatic Hypotension
August 16, 2022
August 9, 2022
Tip of the Week on Vacation
August 2, 2022
Tip of the Week on Vacation
July 26, 2022
More Risks in the Radiology Suite
July 19, 2022
Sucked Out of the Plane at 17,000 Feet
July 12, 2022
Radiologists Racked by Interruptions
July 5, 2022
Tip of the Week on Vacation
June 28, 2022
Pneumonia in Nervous System Injuries
June 21, 2022
June 14, 2022
June 7, 2022
May 31, 2022
NHS Serious Incident Response Framework
May 24, 2022
Requiring Indication for Antibiotic Prescribing
May 17, 2022
Patient Harm in Medicare Inpatients
May 10, 2022
May 3, 2022
April 26, 2022
Challenges with Early Warning Systems
April 19, 2022
April 12, 2022
A Healthcare Worker’s Worst Fear
April 5, 2022
Follow-up on Incidental Findings
March 29, 2022
Disturbing Stats on Perioperative Benzodiazepine Use in Elderly Patients
March 22, 2022
Not Just Politicians That Behave Badly
March 15, 2022
Medication Errors in Home Care
March 8, 2022
Update on Retained Surgical Items
March 1, 2022
Including the Indication on Prescriptions
February 22, 2022
Medication Reconciliation at ICU Exit
February 15, 2022
February 8, 2022
ED to Inpatient Delays Increase Mortality
February 1, 2022
Perioperative Delirium is Not Just Postoperative
January 25, 2022
More on Dental Patient Safety Issues
January 18, 2022
January 11, 2022
Documenting Distractions in the OR
January 4, 2022
Spin or Not: A Useful Secondary Finding in a Study
December 28, 2021
Tip of the Week on Vacation
December 21, 2021
December 14, 2021
Delayed Hemorrhage After Head Trauma in Anticoagulated Patients
December 7, 2021
November 30, 2021
November 23, 2021
The Perils of Hypertonic Sodium Chloride
November 16, 2021
Cognitive Biases and Heuristics in the Delivery Room
November 9, 2021
November 2, 2021
Adverse Drug Events After Hospitalization
October 26, 2021
Opioid-Induced Respiratory Depression Costly in Fiscal as Well as Human Terms
October 19, 2021
COVID-19 Vaccine/ Flu Vaccine Mixups
October 12, 2021
FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?
October 5, 2021
September 28, 2021
Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
September 14, 2021
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
August 31, 2021
The Community Pharmacy and Patient Safety
August 24, 2021
More Home Infusion Safety Issues
August 17, 2021
Tip of the Week on Vacation
August 10, 2021
Tip of the Week on Vacation
August 3, 2021
Obstetric Patients More At-Risk for Wrong Patient Orders
July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
Copyright 2012 The Truax Group Healthcare Consulting Patient Safety Solutions Tools Tips & Resources. All rights reserved.
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax